THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 
MRS.  PRUDENCE  W.  KOFOID 


TREATISE 

ON 

SURGICAL  ANATOMY; 

OR   THE 

ANATOMY  OF  REGIONS, 

CONSIDERED  IN  ITS  RELATIONS  WITH  SURGERY. 

ILLUSTRATED  BY  PLATES, 

REPRESENTING 

THE  PRINCIPAL  REGIONS  OF  THE  BODY. 

BY 

ALF.  A.  L.  M.  VELPEAU,  M.  D.  P. 

Agrege  Stagiaire  to  the  Faculty  of  Medicine  of  Paris,  etc. 
IN  TWO  VOLUMES. 


TRANSLATED  FROM  THE  FRENCH,  WITH  ADDITIONAL  NOTES,  BY 

JOHN  W.  STERLING,  M.  D. 

Member  of  the  Royal  College  of  Surgeons  in  London  ;  Fellow  of  the  College  of 


Physicians  and  Surgeons  of  the  University  of  New-  York,  etc. 


NEW-YORK : 

PUBLISHED  BY  SAMUEL  WOOD  &  S 
No.  261  PEARL-STREET. 
1830. 

H.   &  G.   S.   WOOD,    PRINTERS. 


Southern  District  of  JVeto-ForA;,  t&. 

BE  IT  REMEMBERED,  That  on  the  ninth  day  of  February,  in  the  ritty- 
fpurth  year  of  the  Independence  of  the  United  States  of  America,  John  W.  Ster- 
ling, of  the  said  District,  has  deposited  in  this  office  the  title  of  a  book,  the  right 
whereof  he  claims  as  proprietor,  in  the  words  following,  to  wit  : 

"  A  Treatise  on  Surgical  Anatomy  ;  or  the  Anatomy  of  Regions,  considered  in 
its  relations  with  Surgery.  Illustrated  by  Plates,  representing  the  different  Re- 
gions of  the  Body.  By  Alf.  A.  L.  M.  Velpeau,  M.  D.  P.  Agrege  Stagiaire  to  the 
Faculty  of  Medicine  of  Paris,  etc.  In  two  volumes.  Translated  from  the  French 
by  John  W.  Sterling,  M.  D.,  Member  of  the  Royal  College  of  Surgeons  in  London ; 
Fellow  of  the  College  of  Physicians  and  Surgeons  of  the  University  of  New- York, 
etc." 

In  conformity  of  the  Act  of  the  Congress  of  the  United  States,  entitled,  "An  Act 
for  the  encouragement  of  learning,  by  securing  the  copies  of  Maps,  Charts,  and 
Books,  to  the  Authors  and  Proprietors  of  such  copies,  during  the  time  therein  men- 
tioned ;"  and  also  to  an  Act,  entitled,  "An  Act,  supplementary  to  an  Act,  entitled, 
an  Act  for  the  encouragement  of  learning,  by  securing  the  copies  of  Maps,  Charts, 
and  Books,  to  the  Authors  and  Proprietors  of  such  copies,  during  the  times  therein 
mentioned,  and  extending  the  benefits  thereof  to  the  arts  of  designing,  engraving, 
and  etching  historical  and  other  prints." 

FRED.  J.  BETTS, 

Clerk  of  the  Southern  District  of  New-York. 


TO 

ALEXANDER  H.  STEVENS,  M.D. 

Professor  of  Surgery  in  the  University  of  New- York  ;  Surgeon  to  the  New- York 

Hospital ;  Consulting  Physician  of  the  New- York  City  Dispensary ; 

Member  of  the  New- York  Literary  and  Philosophical 

Society ;  of  the  Academy  of  Natural  Sciences 

of  Philadelphia ;  of  the  Linnean 

Society  of  New-England, 

&c.  &c.  &c. 

WHO,  to  Talents  of  the  highest  order,  great  Scientific  At- 
tainments, and  Professional  Skill,  unites  an  Indefatigable  Zeal  for 
the  promotion  of  Medical  Literature  ;  and  to  whose  Encouragement 
may  be  attributed  this  Humble  Attempt  to  introduce  to  the  general 
notice  of  our  countrymen,  the  Unrivalled  Treatise  of  M.  VELPEAU 
on  SURGICAL  ANATOMY,  is  this  Work  inscribed 
By  his  Greatly  Obliged, 

And  Obed't  Serv't, 

JOHN  W.  STERLING. 

JVeto-ForAr,  Feb.  9,  1830. 


M** 


PREFACE. 


IP  it  is  true  that  indolence,  a  false  judgment,  ignorance,  self-love,  or 
any  other  mistaken  notions,  have  induced  certain  persons  to  say  that 
one  may  be  a  skilful  and  learned  physician  without  being  a  good  anat- 
omist, we  may  affirm  that  this  paradox  will  no  longer  be  revived  at  the 
present  day :  now  that  it  is  the  universal  desire  to  substitute  facts  for 
chimerical  abstractions ;  now  that  the  remains  of  the  dead  constitute 
the  principal  book  in  which  physicians  seek  for  the  cause  of  diseases, 
it  is  no  longer  necessary  to  insist  upon  the  indispensable  necessity  of 
anatomical  knowledge ;  but  there  is  one  branch  of  medicine  to  which 
this  knowledge  appertains  in  a  still  more  intimate  manner,  and  with 
this  opinion  learned  men  have  always  coincided, — I  mean  Surgery. 

Anatomy,  which  is  only  a  collection  of  facts,  though  it  had  been 
cultivated  by  some  few  during  a  long  succession  of  ages,  was  re- 
strained within  very  narrow  limits,  until  the  progress  of  civilization, 
by  banishing  existing  prejudices,  shed  upon  it  the  light  derived  from 
other  branches  of  natural  philosophy.  When  dissections  were  per- 
mitted, discoveries  multiplied  with  rapidity,  and  its  details  became 
formed  into  a  system.  The  more  recent  labours  of  anatomists  have 
so  far  enlarged  the  domain  of  their  science,  that  subdivisions  of  it 
have  become  necesary  both  for  the  study  and  the  improvement  of  it. 

To  examine  the  organic  systems  and  whatever  they  possess  in  com- 
mon  in  every  part  of  the  body,  is  the  object  of  general  anatomy ;  to 
study  the  apparatuses  in  succession ;  to  describe  the  figure,  volume, 
position,  density  and  composition  of  each  organ  is  the  province  of 
descriptive  or  special  anatomy ;  to  take  a  certain  portion  of  the  econ- 
omy, describe  all  the  elements  which  are  comprised  within  it,  and 
point  out  the  peculiarities  which  each  of  them  present ;  the  direction 
and  exact  relations  of  the  most  important  objects ;  the  varieties  of 
thickness  and  position  produced  by  diseases  or  aberrations  of  devel- 
opement ;  to  proceed  from  the  skin  towards  the  bones,  or  from  the 
hones  towards  the  surface,  and  thus  observe  successively,  and  layer  by 


Vi  PREFACE. 

layer,  in  their  relative  and  natural  position,  the  different  parts,  withou; 
entering  into  minute  details ;  this  is  what  constitutes  the  anatomy  oi* 
regions  or  of  relations,  or  topographical  anatomy. 

The  first,  more  particularly  concerned  with  the  fibrillary  arrange- 
ment, and  the  analysis  of  the  intimate  structure  of  the  tissues,  is  the 
basis  of  all  sound  physiology ;  without  it,  medicine  would  never  have 
emerged  from  that  confusion  of  principles  which  so  long  prevailed  in 
the  schools :  it  truly  deserves  the  title  of  medical  anatomy. 

The  second,  displaying  the  organs  in  the  manner  which  nature  pre- 
sents them,  describing  their  most  prominent  characters,  without  in- 
vestigating their  molecular  disposition,  or  those  unknown  vital  proper- 
ties from  which  they  derive  life  and  motion,  appertains,  more  directly 
to  surgery,  which  owes  to  it  its  rapid  progress  and  the  certainty  with 
which  it  is  honoured :  without  it,  the  surgeon  would  be  but  a  danger- 
ous man. 

The  third  is  as  yet  altogether  new,  and  can  only  be  considered  as  a 
complement  of  the  two  others.  It  differs  from  common  descriptive 
anatomy,  both  by  the  end  which  it  proposes  and  the  means  it  employs. 
This  takes  up  one  apparatus  of  organs  and  follows  it  to  every  part  to 
which  it  is  distributed,  previous  to  taking  up  the  consideration  of  the 
others ;  that,  on  the  contrary,  passes  in  review  all  the  elements  of  a  cir- 
cumscribed point,  without  investigating  either  their  origin  or  termina- 
tion. The  one  tends  to  make  known  the  special  functions  of  the  econo- 
my ;  the  other  to  expose  the  different  characters  of  this  or  that  part  of  the 
body ;  to  give  the  mechanical  reason  for  the  diverse  phenomena  which 
we  remark  in  it ;  to  explain  the  difference  in  the  dangers  and  forms  of 
diseases,  by  the  difference  in  the  relative  and  visible  disposition  of  the 
systems  which  compose  this  or  that  region ;  it  dwells  upon  some  or- 
gan?, passes  lightly  over  others,  always  seeks  to  place  itself  in  relation 
with  operations ;  in  a  word,  it  is  the  anatomy  which  is  most  intimately 
connected  with  external  pathology,  and  which,  for  this  reason,  is  called 
Surgical. 

Some  positive  notions  upon  surgical  anatomy  and  the  anatomy  of 
regions,  were  first  promulgated  by  Desault,  in  his  oral  lectures ;  and 
all  who  enjoyed  the  benefit  of  hearing  this  celebrated  surgeon,  agree  in 
saying  that  he  felt  its  great  importance ;  but  baron  Boyer  is  the  first 
author  who  has  written  upon  this  subject,  and  his  immortal  work  on 
anatomy  contains  a  sketch  of  an  anatomy  of  regions  which  must  dispose 
us  to  regret  that  he  did  not  enter  more  fully  into  this  matter.  I  say  the 
first,  for  the  Treatise  on  Surgical  Anatomy  by  Palfin,  published  in  the 
beginning  of  the  last  century,  is  a  very  indifferent  work,  decorated  with 


PREFACE.  Vll 

a  vain  title.  That  of  Petit  was  composed  after  the  same  model,  and 
deserves,  in  a  great  measure,  the  same  censure ;  neither  of  these  au- 
thors had,  in  fact,  investigated  this  subject  under  its  proper  aspect. 

Professor  Roux  next  attempted  to  incorporate  it  with  his  course  of 
lectures,  and  he  undoubtedly  deserves  the  honour  of  directing  the  at- 
tention of  the  students  of  the  school  of  Paris  to  this  particular  branch 
of  anatomy.  Several  theses,  written  after  the  model  of  his  lectures, 
shew  that  M.  Roux  then  considered,  and,  from  what  I  have  heard  him 
express,  still  considers  surgical  anatomy  under  two  different  points  of 
view.  On  the  one  hand,  he  would  that  all  the  organic  apparatuses 
were  examined  in  succession,  according  to  their  relations  with  surge- 
ry: thus,  the  skin,  cellular  tissue,  muscles,  etc.,  should  be  successive- 
ly studied  in  this  manner,  and  the  theses  of  M.  Baget  upon  the  cellu- 
lar tissue,  of  Bajeard  upon  the  muscular  tissue,  were  arranged  accord- 
ing to  this  method ;  this  is  what  M.  Roux  proposed  calling  general 
surgical  anatomy.  On  the  other  hand,  he  thought  that  we  should  in- 
vestigate all  the  organs  in  their  relative  situations,  which  would  consti- 
tute the  anatomy  of  regions,  properly  so  called.  But  he  who  under- 
took to  continue  the  descriptive  anatomy  of  the  most  brilliant  genius  of 
our  age,  was  shortly  after  called  upon  to  attend  to  other  duties,  and  the 
impulse,  which  had  been  given  with  so  much  advantage  to  anatomical 
students,  sensibly  diminished.  Its  utility,  however,  was  not  forgotten. 
Already  had  it  attracted  the  attention  of  Beclard,  who  entered  upon  its 
investigation  with  so  much  assiduity,  that  he  soon  transformed  the 
projects  of  M.  Roux  into  reality.  To  the  natural  divisions  of  the  body, 
he  added  secondary  divisions ;  he  circumscribed  the  principal  regions, 
and  the  sketch  which  he  made  of  topographical  anatomy,  in  his  course 
to  the  Faculty  of  Paris,  presented  itself  under  an  aspect  so  imposing 
to  the  numerous  students  who  were  eager  to  hear  him,  that  it  thence- 
forth became  the  favourite  study  of  the  greater  proportion  of  them. 
Indeed,  it  is  sufficient  to  turn  to  the  articles  Axilla,  Jlrm,  Elboiv,  Fore- 
arm, Ham,  etc.,  which  he  has  contributed  to  the  Nouveau  Dictionnaire 
de  Medicine,  in  order  to  have  an  idea  of  the  interesting  remarks  which 
accompanied  his  descriptions.  It  is  from  him,  from  his  instructive 
lessons,  as  well  as  those  of  an  equally  revered  professor,  M.  Marjolin, 
that  young  surgeons  imbibed  a  taste  for  this  subject;  but  students 
wanted  a  guide,  an  elementary  work  to  direct  them ;  Beclard  had  pro- 
mised to  furnish  it;  it  was  eagerly  anticipated,  and  every  thing  favour- 
ed the  belief  that  it  would  soon  have  been  presented  to  the  public,  if  a 
premature  death  had  not  deprived  anatomy  of  one  of  its  brightest  orna- 
ments and  firmest  supports.  This  professor  has  left,  in  this  respect, 


Vlll  PREFACE. 

as  well  as  in  many  others,  a  chasm  which  it  is  very  difficult  to  fill  up, 
and  which  is  so  much  the  more  severely  felt  in  the  science,  as  we  begin 
generally  to  admit,  at  the  present  day,  that  the  anatomy  of  the  regions 
is  less  dry,  and  that  it  is  of  still  more  immediate  application  in  sur- 
gery than  descriptive  anatomy,  such  as  it  is  exposed  in  our  best  treati- 
ses. It  is  with  the  view  of  closing  this  hiatus  that  I  have  undertaken 
to  present  to  the  public  an  Essay  on  Surgical  Anatomy,  and  the  Anat- 
omy of  Regions.  I  do  not  presume  sufficiently  upon  my  own  abilities 
to  suppose  that  I  have  fully  accomplished  my  object :  I  merely  thought 
that  it  would  be  agreeable,  to  students  especially,  to  possess  some  book 
upon  this  subject,  whilst  waiting  for  some  more  capable  person  to  en- 
gage in  it,  or  until  I  could  produce  a  better  myself.  However,  I  have 
neglected  nothing  that  might  render  this  work  useful  to  the  greater 
number,  and  I  must  say  that  I  did  not  undertake  it  until  I  had  long  re- 
flected upon  it.  It  is  to  M.  J.  Cloquet,  one  of  my  first  preceptors  in 
Paris,  that  I  am  indebted  for  the  first  idea  of  it ;  we  began  together  at 
the  Hospital  Saint  Louis,  in  1821;  the  regions  were  already  traced, 
when  the  attention  of  this  learned  anatomist  was  called  to  other  la- 
bours. Nevertheless,  I  did  not  abandon  this  project,  and  in  1822, 1 
submitted  our  plan  to  some  students,  to  whom  I  gave  a  course  upon 
this  subject  in  the  amphitheatre  of  the  E' cole- Pratique.  Since  then  I 
have  not  ceased  occupying  myself  with  it,  and  I  have  closed  my  ana- 
tomical demonstrations  every  year  with  some  lectures  upon  surgical  and 
topographical  anatomy :  thus,  by  teaching,  I  have  been  enabled  to  make 
trial  of  several  different  methods.  That  which  I  have  at  length  adopted, 
is  not  altogether  the  same  with  the  plan  which  I  pursued  at  first;  nei- 
ther is  it  analogous  to  that  of  Professor  Beclard.  Having  no  model  to 
copy  after,  I  was  obliged  to  depend  upon  my  own  judgment;  I  sought, 
however,  to  enlighten  myself  by  every  possible  means  previous  to 
deciding.  For  the  divisions  I  consulted  the  manual  of  Rosenthal,  pro- 
fessor at  Berlin,*  but  the  only  one  I  am  acquainted  with,  in  which  all 
the  regions  of  the  body  are  described ;  an  essay  of  Doctor  Bock,f 
printed  at  Leipsic,  in  1824,  accompanied  with  three  figures,  in  which 
arbitrary  lines,  serving  to  limit  a  certain  number  of  sections,  are  trac- 
ed ;  the  thesis  of  M.  Gerdy,  my  colleague  to  the  Faculty,  published  in 
1823,+  and  in  which  we  find  a  topographical  sketch  of  the  different 
parts  of  the  body  of  man  considered  in  nearly  the  same  point  of  view  as 
in  the  work  of  M.  Boyer.  It  will  be  easy  to  see  how  far  I  differ  in 
this  respect,  from  these  authors,  and  in  what  degree  I  approximate  to 

*Handbuch  der  chirurgischen  Anatomic.  Berlin,  1817.        f  Der  raenschlische 
Korper,  etc.  von  Dr.  August  Carl  Bock.        J  No.  143,  page  29. 


PRKFACE.  IX 

them.  For  several  years  also,  my  friends,  MM.  Bouvier,  associate, 
Blandin,  Bogros,  prosectors,  and  Amussat,  anatomical  assistant  to 
the  faculty,  have  been  engaged  in  teaching  the  anatomy  of  regions 
with  much  success,  but  as  they  have  not  published  the  plan  which  they 
follow,  I  have  not  been  able  to  profit  by  their  knowledge,  nor  ascer- 
tain in  what  measure  their  method  differs  from  mine. 

With  respect  to  the  fundamental  part,  I  have  drawn  from  all  the 
sources  which  I  have  been  able  to  discover ;  and  I  mention  them  here, 
in  order  that  I  may  avoid  too  frequent  citations  in  the  text,  and  also 
that  every  person  may  there  resume  whatsoever  appertains  to  him. 
I  have  especially  had  recourse  to  such  works  as  treat  particularly  of  a 
given  point  of  the  body ;  and  I  will  mention,  among  others,  for  the 
Eye,  the  works  of  Zinn,  Simmering,  Demours ;  some  numbers  of 
the  Bibliotheque  Chirurgicale  of  Langenbeck,  the  book  published  at 
Berlin  in  1822  by  Weller ;  for  the  lachrymal  passages,  a  very  good 
thesis  of  M.  Vesigne,  that  of  M.  Dubois,  Jun. ;  for  the  anatomy  of 
the  Neck  and  Head,  the  treatise  of  Allan  Burns,  one  of  the  best  worksj 
on  this  subject,  which  have  appeared  in  England,  although  it  does  not 
merit  all  the  praise  which  it  has  received  in  the  country  of  its  author. 
In  fact,  it  is  not  a  treatise  on  surgical  anatomy,  nor  of  the  regions  of 
the  head  and  neck  ;  it  would  be  better  intituled — Chirurgical  Obser- 
vations, accompanied  with  anatomical  remarks  ; — that  of  Doctor  Col- 
les,  published  in  1811,  and  which  also  treats  of  the  surgical  anatomy 
of  the  thorax,  abdomen  and  pelvis ;  it  enters  less  into  detail  than  that 
of  Burns,  but  is  more  purely  anatomical ;  a  very  fine  engraving  of 
the  neck  by  Astley  Cooper,  in  one  of  the  German  journals  for  1825  ;* 
other  plates  of  M.  Langenbeck,  representing  the  parotideal  region  and 
divers  other  points  of  the  head  and  neck  ;  the  fourth  table  of  Santo- 
rini,  one  of  Scemmering  upon  the  nasal  fossae,  mouth  and  pharynx ; 
the  works  of  J.  Fabrice  and  Duverney  upon  the  Ear ;  of  MM.  Des- 
champs  and  H.  Cloquet,  upon  the  nostrils,  etc.;  for  the  axilla  the 
theses  of  M.  Mey  (1817,  No.  63) ;  and  of  M.  Beulac  (1819,, 
No.  220)  arranged  according  to  the  lectures  of  M.  Roux  ;  that  of  M. 
Senelle  (1822,  No.  143)  upon  the  thoracic  extremity ;  for  the  shoul- 
der, the  fingers,  foot  thigh,  perinaeum  of  the  female,  the  canal  of  the 
urethra,  etc.  several  memoires  of  M.  Lisfranc  ;  for  the  different  parts 
of  the  pelvis,  perinaeum,  groin,  the  researches  of  Camper,  and  the 
plates  executed  in  part  under  the  inspection  of  this  celebrated  author  ; 
the  splendid  work  of  W.  Hunter  upon  the  pelvis  and  gravid  uterus  ; 
that  of  Hesselbach,  who  has  so  correctly  described  the  disposition  of 

*  Chirurgische  Kupfortafeln. 


X  1'REFACJi. 

the  aponeuroses  of  the  fold  of  the  groin,  and  the  relations  of  the  epi- 
gastric artery  in  hernia,  in  1806,  1816,  and  1819  ;  those  of  M.  J.  Clo- 
quet,  Astley  Cooper,  Hey,  Lawrence,  upon  the  same  subject  and  her- 
nia in  general ;  the  thesis  of  M.  Breschet,  on  crural  hernia ;  the  re- 
searches of  Langenbeck,  in  1802,  and  of  M.  Dupuytren,  in  1812, 
upon  lithotomy  and  the  perinaeum ;  of  MM.  Carcassonne  and  Bou- 
vier,  upon  the  aponeuroses  of  the  pelvis ;  Bogros,  upon  the  iliac  re- 
gion ;  Sanson  and  Scarpa,  upon  the  recto-vesical  lithotomy  ;  several 
memoires  of  the  latter,  and  his  elegant  plates  upon  aneurisms,  herniae 
and  hydrocele  ;  the  first  part  of  the  system  of  surgical  anatomy  by  Dr. 
W.  Anderson,  upon  the  groin,  pelvis  and  perinaeum,  published  at  New- 
York,  in  1822  ;  the  essay  whicn  Dr.  Ashton  Rey  has  just  published  in 
London,  upon  the  section  of  the  prostate  in  lithotomy,  according  to  the 
process  of  Cheselden,  and  his  plates  upon  the  pelvis ;  finally,  the 
thesis  of  M.  Senn,  of  Geneva,  upon  the  perinecum  and  the  different 
forms  of  perinseal  lithotomy.  I  ought  also  to  note  three  drawings 
which  are  found  in  the  memoir  of  Dr.  Liston,  published  in  London,  in 
1811,  upon  the  fold  of  the  groin ;  the  work  of  Groefe  upon  amputa- 
tions, printed  at  Berlin,  in  1812 ;  (on  this  subject,  I  would  remark, 
that  I  have  passed  by  the  name  of  this  celebrated  surgeon  in  silence, 
when  speaking  of  the  staphyloraphy,  not  because  I  was  ignorant  of  his 
having  performed  this  operation  in  1816,  and  a  considerable  number 
of  times  since  ;  but  because  the  method  of  M.  Roux,  which  actually 
seems  to  have  originated  with  him  in  France,  deserves  the  preference 
in  every  respect);  the  system  of  surgical  operations,  began  by  Charles 
Bell  in  1821  ;  the  Manual  of  Jlnatomy  by  Stanley,  and  which  is  in 
fact  an  abridgement  of  the  anatomy  of  regions  ;  that  of  Green  ;  and 
even  that  of  Shaw ;  the  Anatomical  System  of  Lizars,  just  published 
in  London ;  lastly,  I  would  cite  a  treatise  upon  the  aponeuroses  by 
Dr.  Godman  of  Philadelphia,  and  another  meritorious  work  upon  the 
surgical  anatomy  of  the  arteries,  by  Robert  Harrison  of  Dublin,  both 
of  which  appeared  in  1824-5. 

With  respect  to  classic  treatises,  I  have  principally  derived  assist- 
ance from  those  of  Bichat,  MM.  Boyer,  Portal,  H.  Cloquet,  and  J. 
Cloquet,  for  the  anatomy ;  the  manual  of  the  celebrated  F.  Meckel, 
has  also  been  of  much  service  to  me,  especially  as  it  regards  the  varie- 
ties and  anomalies  of  position.  For  the  surgical  part  I  have  made  use 
of  the  excellent  book  of  Sabatier,  as  well  as  the  additions  of  its  new 
editors.  I  might  cite  at  every  page  the  treatise  on  Surgical  Diseases 
by  M.  Boyer,  and  the  Nosographie  of  M.  Richerand,  I  have  especially 
borrowed  from  the  latter  professor  a  part  of  the  lines  which  be  first  in- 


PREFACE.  XI 

dicated  for  the  purpose  of  discovering  the  direction  of  the  principal 
arteries  of  the  extremities.     In  a  word,  I  have  endeavoured  to  profit 
by  the  numerous  works  which  have  been  published,  during  a  century, 
upon  anatomy  and  surgery,  in  France  as  well  as  hi  England,  Ger- 
many, Italy,  etc.;  and,  as  regards  this,  I  take  this  opportunity  of  pre- 
senting my  acknowledgements  to  Dr.  Crawford  of  London,  for  the 
zeal  and  activity  which  he  has  manifested  in  procuring  for  me  the 
works  which  I  had  need  of,  and  to  M.  Wessley,  doctor  in  medicine 
of  the  University  of  Gottingen  for  the  assistance  he  has  afforded  in 
enabling  me  to  understand  the  numerous  publications  in  the  German 
language.     Also  to  M.  Paillard,  internal  surgeon  to  the  civil  hospitals, 
my  friend  and  former  condisciple  at  the  Hospital  St.  Louis,  who,  hav- 
ing been  for  a  long  time  prosector  to  M.  Lisfranc,  and  engaged  for 
several  years  in  surgical  anatomy,  has  collected  an  abundance  of  ma- 
terials, both  on  the  subject  of  general  surgical  anatomy  and  the  anat- 
omy of  regions,  which  cannot  fail  being  useful  to  the  science,  if  he 
publishes  them,  as  he  has  promised.     By  placing  his  manuscripts  at 
my  disposal,  he  has  given  me  a  proof  of  confidence  which  does  honour 
to  his  character,  and  which  it  is  my  duty  thus  publicly  to  acknowledge. 
A  combination  of  circumstances  so  favourable  imposes  upon  me, 
I  am  well  aware,  great  obligations.     My  province  has  been  rather  to 
make  a  selection  among  a  multitude  of  facts  than  to  search  too  mi- 
nutely after  new  ones.     Nevertheless  as  the  subject  was  not  before 
surveyed  from  the  same  point  of  view,  and  as  the  objects  of  it  were 
appreciable ;  as  the  most  scrupulous  exactness  in  the  relative  posi- 
tion of  the  parts  is  the  chief  merit  and  distinguishing  character  of  a 
Treatise  on  Surgical  Anatomy,  I  have  considered  it  my  duty  to  de- 
rive this  from  Nature  alone.     Therefore,  all  the  regions  have  been 
circumscribed  upon  the  dead  body,  and  I  have  not  indicated  a  part, 
described  a  layer,  or  given  a  measurement  without  having  a  subject 
before  me.     It  was  not  until  I  had  repeatedly  examined  the  different 
elements  of  a  region  that  I  had  recourse  to  authors  or  ventured  com- 
mitting them  to  paper  ;  then  if  my  descriptions  coincided  with  those  of 
the  most  accurate  anatomist,  I  considered  them  correct ;  but  if,  on  the 
contrary,  they  differed,  I  again  returned  to  interrogate  the  dead  body 
and  forbore  to  contradict  until  I  had  established  the  certainty  that  some 
circumstance  had  deceived  them.     In  this  manner,  I  have  only  dwelt 
upon  the  description  of  parts  in  proportion  to  their  degree  of  import- 
ance, and  with  some  I  have  entered  more  into  detail  than  is  usually 
done  in  elementary  treatises :  such,  as  for  example,  the  cellular  tis- 
sue, the  different  aponeuroses,  and  the  layers  which  are  derived  from 


Xll  . 

them.  It  is,  in  fact,  only  in  investigating  anatomy  by  regions  that  we 
can  conveniently  dwell  upon  the  disposition  of  these  laminae,  which 
actually  deserve  additional  investigation ;  on  the  other  hand,  I  have 
thought  proper  to  omit  many  indifferent  minutiae  which  relate  to  sur- 
gery, although  they  might  afford  great  interest  in  a  treatise  on  de- 
scriptive anatomy. 

With  respect  to  the  numerous  preparations  required,  and  all  that  por- 
tion of  this  labour  which  it  was  necessary  to  perform  in  the  dissecting 
room,  I  have  derived  assistance  from  several  persons,  and  I  cannot. 
on  this  occasion,  give  too  much  credit  to  my  prosector  M.  Bintot,  for 
the  accuracy  which  he  has  exhibited.  To  M.  Ch.  Delange,  an  enter- 
prising student  of  the  Faculty  of  Medicine  of  Paris,  more  than  any 
other,  I  owe  a  testimonial  of  gratitude  for  the  entire  devotion  which  he 
has  shewn  me  in  this  respect,  and  for  the  active  part  which  he  has  not 
ceased  to  take  in  every  thing  that  concerns  this  work. 

Detained  a  long  time  by  the  first  step,  that  is  to  say,  by  the  division 
which  it  would  be  most  proper  to  establish,  and  by  the  number  of  re- 
gions which  might  be  usefully  admitted,  I  was  apprehensive  of  falling 
into  two  opposite  extremes  :  too  multiplied,  they  would  fatigue  the 
memory  and  occasion  incessant  repetitions  ;  too  few,  they  would  not 
enable  us  to  display  advantageously  every  important  part  contained 
within  them.  The  great  natural  sections  of  the  body  being  insufficient, 
I  have  substituted  for  them  arbitrary  lines,  which  I  have  connected,  as 
much  as  was  possible,  with  osseous  or  muscular  eminences.  These 
lines  seem  to  me  to  present  the  inappreciable  advantage  of  embracing 
in  a  given  region,  objects  which  can  only  afford  surgical  interest  so 
long  as  we  consider  them  united  and  in  their  natural  connexions  :  thus, 
should  we  separate  the  arm  from  the  fore-arm,  the  elbow  would  remain 
without  importance  ;  the  considerations  relative  to  blood-letting,  to  the 
formation  of  aneurism  in  this  region,  would  no  longer  be  applicable  ; 
if  the  arm  ceased  to  be  connected  with  the  shoulder,  the  axilla  would 
no  longer  exist ;  finally,  it  is  in  the  environs  of  the  principal  folds  of 
the  limbs  that  the  most  severe  and  important  surgical  operations  are 
performed.  But  these  lines  might  have  been  established  in  diverse 
manners  ;  they  might  have  been  more  or  less  approximated  or  differ- 
ent directions  given  them,  etc.  Every  one  doubtless  will  have  his 
particular  opinion  on  this  subject.  Those  which  I  have  traced  seem 
to  me  to  fulfil  tolerably  well  the  principal  indications ;  however,  I 
attach  very  little  importance  to  them,  and  if  it  can  be  demonstrated  to 
me  that  I  might  have  chosen  others  of  more  general  utility,  I  will  be 
the  first  to  modify  them. 


PREFACE.  Xlll 

The  order  of  arranging  the  descriptions  caused  still  greater  embar- 
rassment, because  it  is  more  connected  with  the  most  prominent  part 
of  the  subject.  At  first,  I  found  it  more  natural,  more  physiological 
to  begin  the  examination  of  a  region  with  its  skeleton,  and  terminate 
it  with  the  cutaneous  envelope  :  but  this  book  being  particularly  des- 
tined for  those  who  study  or  operate  upon  the  dead  body,  I  thought 
that  it  would  be  more  convenient  for  them  if  the  inverse  method  was 
adopted.  The  first  is  altogether  synthetical,  and  can  only  be  of  use 
to  those  who  have  already  acquired  the  knowledge,  or  who  labour 
in  the  silence  of  the  closet.  The  second,  on  the  contrary,  truly  ana- 
lytical, seems  to  me  perfectly  to  fulfil  the  end  of  the  student  and 
operator,  displaying  the  different  organs  in  the  order  in  which  they 
present  themselves  under  the  knife,  it  admits  of  their  being  studied 
better,  and  it  is  more  surgical  and  more  anatomical. 

As  it  regards  the  fundamental  plan  and  the  nature  of  the  work,  I 
have  selected  from  several  methods  which  naturally  presented  them- 
selves to  my  mind.  I  might  have  restricted  myself  to  enumerate  in 
each  region,  and  layer  by  layer,  without  distinction  of  tissue  or  of  or- 
gans, the  parts  which  compose  it ;  but  then  it  would  have  been  diffi- 
cult to  give  a  distinct  perception  of  their  precise  relations.  By  taking 
successively  each  system  in  particular,  it  has  not  always  been  possible 
for  me  to  follow  exactly  the  order  of  superposition  of  the  organic 
planes  ;  but  I  found  that  it  was  the  easiest  method  of  pointing  out  the 
principal  peculiarities  and  positive  relations  of  each  organ  with  those 
which  surround  it.  It  appeared  to  me  also  that,  by  this  method,  the 
descriptions  would  be  less  burthensome  to  the  memory  and  better  un- 
derstood :  however,  although  the  anatomy  would  have  been  a  little  less 
dry  and  uninteresting,  presented  under  this  point  of  view  than  under 
the  preceding,  it  would  not  have  attained  its  principal  object  of  utility ; 
it  would  not  have  been  surgical.  Finally,  I  might,  in  the  first  place, 
have  described  each  system,  and  afterwards  the  surgical  remarks  which 
appertain  to  it,  after  the  manner  of  several  English  surgeons,  and 
especially  MM.  Anderson  of  New-York,  and  Harrison  of  Dublin,  as 
well  as  of  MM.  Lawrence,  Scarpa,  Boyer,  etc.,  in  treating  of  hernise  ; 
but  then  this  would  have  been  a  treatise  on  descriptive  anatomy  on  the 
one  part,  and  on  surgery  on  the  other.  As  all  these  modes  of  investi- 
gation conduct  more  or  less  directly  towards  the  end  which  I  proposed 
myself,  and  in  another  sense  deviate  from  it,  I  have  attempted  to  amal- 
gamate them,  lopping  off  whatever  was  superfluous  or  foreign  to  my 
subject,  endeavouring  to  combine  surgical  anatomy  with  that  of  the  re- 
gions, and  surgical  anatomy  by  system  of  organs,  with  topographical 


XIV  PREFACE. 

anatomy  and  the  anatomy  of  relations,  without  establishing  any  dis- 
tinction between  them. 

To  recapitulate  : — I  have  had  no  intention  of  making  a  treatise  on 
anatomy  to  supply  the  place  of  those  which  we  already  possess,  nor  a 
book  of  surgery  nor  of  operations,  but  to  collect  in  each  point  of  the 
body  of  man  the  knowledge  which  naturally  flows  from  the  parts  which 
we  there  meet  with  :  to  propose  an  anatomy,  by  the  aid  of  which  the 
surgeon  may  always  foresee,  previous  to  practising  any  operation  what- 
soever, all  the  accidents  which  may  immediately  follow  it,  and  all  the 
precautions  which  it  requires  relatively  to  the  parts  which  should  be  pre- 
served or  avoided  ;  by  the  aid  of  which,  one  point  of  the  body  being 
given,  it  will  be  possible  to  tell,  within  a  few  lines,  what  are  the  fibrillae, 
arteries,  veins,  nerves,  muscles,  etc.,  which  must  lie  in  the  way  of  the 
instrument ;  and  it  was  with  the  view  of  accomplishing  this  end  still 
more  effectually,  that  I  was  disposed  to  describe  from  the  central  point 
to  the  periphery,  upon  sections  made  at  different  heights  of  the  trunk 
and  extremities,  all  the  objects  which  present  themselves  to  the  eye. 
I  was  also  inclined  to  traverse  the  body  in  a  great  number  of  directions 
and  at  different  points,  with  metallic  rods,  in  order  to  indicate,  by  leav- 
ing them  in  place,  the  nature  and  situation  of  the  organs  thus  trans- 
fixed ;  but  I  was  apprehensive  of  making  the  work  too  voluminous, 
and  therefore  have  reserved  this  project  until  a  future  opportunity. 

It  is  especially  in  the  anatomy  of  relations  that  designs  well  executed 
would  be  of  great  assistance  ;  for  by  a  simple  glance  at  a  region  cor- 
rectly represented,  the  mind  seizes,  embraces  much  better  what  is  re- 
quired to  be  acquainted  with  than  by  means  of  a  lengthy  description  ; 
and  in  default  of  dead  bodies,  I  know  of  nothing  that  can  be  substi- 
tuted for  plates.  Those  which  accompany  this  treatise  have  been 
drawn  from  nature  by  M.  Chazal,  one  of  our  most  distinguished  artists, 
the  person  who  is  employed  in  executing  the  elegant  designs  for  M. 
Maygrier's  work  upon  accouchemens.  I  was  at  first  disposed  to  profit 
by  his  skilful  pencil,  in  order  to  represent  a  much  greater  number  of 
regions  under  different  aspects,  but  I  soon  perceived  that  this  would 
increase  the  price  of  the  work  far  beyond  what  would  be  convenient  for 
the  greater  number  of  the  readers  to  whom  I  address  it. 

Finally,  in  order  that  this  work  might  be  what  it  ought  to  be,  still 
more  numerous  researches,  and  a  greater  length  of  time  than  I  have 
been  able  to  devote  to  it,  are  necessary.  I  am  well  aware  that  it  has 
many  defects,  and  criticism  will  unveil  others  which  I  am  not  con- 
scious of.  I  have  hastened  to  publish  it  for  the  winter,  in  order  that 
students  might  make  use  of  it  during  the  session  which  is  about  to 


PREFACE.  XV 

open  ;  with  the  view  also  of  exciting  others  to  works  of  this  kind,  and 
of  attracting  the  attention  of  surgeons  and  anatomists  to  a  subject 
which  must  be  productive  of  great  practical  benefit.  I  have  done 
every  thing  in  my  power  to  render  it  useful  and  to  avoid  advancing 
what  was  not  correct  ;  if,  however,  blemishes  too  numerous  should  be 
discovered  in  it,  my  only  apology  is  a  sincere  desire  to  remove  them 
hereafter,  and  my  grateful  acknowledgements  to  those  who  will  kindly 
point  them  out  to  me.  I  must  also  claim  some  indulgence  ;  requesting  it 
to  be  kept  in  remembrance  that  it  became  necessary  for  me  to  trace  the 
way,  and  that  "on  ne  fait  point  de  P  anatomic  par  la  seule  force  de  la 


PARIS,  November  1st,  1825, 


TABLE  OF  CONTENTS. 
VOL.  I. 


PREFACE 

CHAPTER  I.  OF  THE  HEAD, 

ARTICLE  I.  OF  THE  CRANIUM, 
Sect.  1.  Frontal  Region, 

CONSTITUENT  PARTS. 

1.  The  Skin, 

2.  The  Cellule-Adipose  Layer, 

3.  The  Muscles  and  Aponeurosis, 

4.  The  Pericranium, 

5.  The  Arteries, 

6.  The  Veins, 

7.  The  Lymphatic  Vessels, 

8.  The  Nerves, 

9.  The  Skeleton, 


Sect.  4.  Cranium  in  general, 
I  ARTICLE  II.  OP  THE  FACE, 
1  Sect.  1.  Parotideal  Region, 

1  CONSTITUENT  PARTS. 

1.  The  Skin, 

2.  The  Subcutaneous  Layer, 

2  3.  Of  the  External  Ear, 

2  4.  The  Middle  Ear  or  Tympanum, 

3  5.  The  Parotid  Gland, 
3       6    The  Muscles, 

3  7.  The  Arteries, 

4  8.  The  Veins, 

4  9.  The  Nerves, 

5  10.  The  Lymphatics, 
5     11.  The  Skeleton, 


Sect.  2.  Temporo- Parietal  Region,  7    Sect.  2.  Nasal  Region, 


CONSTITUENT  PARTS. 

1.  The  Skin,  8 

2.  The  Cellulo- Adipose  Layer, 

3.  The  Epicranial  Aponeurosis,  9 

4.  The  Temporal  Aponeurosis,  9 

5.  The  Muscles,  10 

6.  The  Arteries,  10 

6.  The  Veins,  11 

7.  The  Lymphatics,  13 

8.  The  Nerves,  12 

9.  The  Skeleton,  13 

Sect.  3.  Occipital  Region,  14 

CONSTITUENT  PARTS. 

1.  The  Skin,  15 

2.  The  Cellulo- Adipose  Layer,  15 

3.  The  Aponeurogis  and  the  Muscles,   15 

4.  The  Pericranium,  16 

5.  The  Arteries,  16 

6.  The  Veins,  16 

7.  The  Lymphatics,  17 

8.  The  Nerves,  17 

9.  The  Skeleton,  18 


CONSTITUENT  PARTS. 

1.  The  Skin, 

2.  The  Cellular  Layer, 

3.  The  Muscles, 

4.  The  Arteries 

5.  The  Veins, 

6.  The  Lymphatics, 

7.  The  Nerves, 

8.  The  Bones  and  Cartilages, 

Sect.  3.  Orbitary  Region, 

CONSTITUENT  PARTS. 

1.  The  Supra- Orbital  or  Supercilia 

ry  Arcade, 

2.  The  Superior  Palpebra, 

3.  The  Inferior  Palpebra, 

A.  The  Skin.— B.  The  Cellular 
Tissue. — C.  The  Muscles.— D. 
The  Palpebral  Ligament.— E.  The 
Cartilages  of  the  Tarsi.— F.  The 
Conjunctiva. — G.  The  Palpebral 
Follicles,  or  Glands  of  Meibomius. 
H.  The  Arteries.— J.  The  Veina. 


22 


23 
23 
24 
26 
29 
31 
32 
33 
34 
35 
36 

37 


37 
38 
38 
38 
39 
39 
39 
40 

41 


41 

44 
45 


XV111 


CONTENTS. 


K.  The  Lymphatics.  —  L.  The 
Nerves.—  M.  The  Cilia.—  N.  The 
Sub-Orbital  Arcade.—  O.  The  Tem- 
poral angle  of  the  Palpebras.  —  P. 
The  Great  Angle.  —  Q.  The  Lach- 
rymal Puncta  and  Canals.  —  R. 
The  Lachrymal  Sac.—  S  The  Or- 
bitary  Portion,  properly  called.  45-56 

Sect.  4.  Zygomato-MaxUlary  Region,     73 


CONSTITUENT  PARTS. 

1.  The  Skin, 

2.  The  Cellulo-Adipose  Tissue, 

3.  The  Muscles, 

4.  The  Arteries, 

5.  The  Veins, 

6.  The  Lymphatics, 

7.  The  Nerves, 

8.  The  Skeleton, 

Sect.  5.  Masseteric  Region, 

CONSTITUENT  PARTS. 

1.  The  Skin, 

2.  The  Subcutaneous  Layer, 

3.  The  Muscles, 

4.  The  Arteries, 

5.  The  Veins, 

6.  The  Lymphatics, 

7.  The  Nerves, 

8.  The  Canal  of  Steno, 

9.  The  Skeleton, 

Sect.  6.  The  Genial  Region, 

CONSTITUENT  PARTS. 

1.  The  Skin, 

2.  The  Adipose  Tissue, 

3.  The  Muscles, 

4.  The  Canal  of  Steno, 

5.  The  Arteries, 

6.  The  Veins, 

7.  The  Lymphatics, 

8.  The  Nerves, 

9.  The  Mucous  Membrane, 

10.  The  Skeleton, 

Sect.  7.  Mental  Regim, 

CONSTITUENT  PARTS. 

1.  The  Skin, 

2.  The  Cellular  Tissue., 

3.  The  Muscles, 

4.  The  Arteries, 

5.  The  Veins, 

6.  The  Lymphatics, 

7.  The  Nerves, 

8.  The  Skeleton, 


74 
74 
75 

76 
76 
77 

77 
78 

79 


79 
79 
80 
80 
81 
81 
81 
81 


85 


Sect.  8.  Labial  Region, 
Superior  Lip, 

CONSTITUENT    PARTS. 

1.  The  Skin, 

2.  The  Cellular  Tissue, 

3.  The  Muscles, 

4.  The  Arteries, 

5.  The  Veins, 

6    The  Lymphatics, 

7.  The  Nerves, 

8.  The  Skeleton, 


Inferior  Lip, 


93 
94 


94 
95 
95 
96 
96 
97 
97 
97 

98 


CONSTITUENT  FARTS. 


1.  The  Skin— 2.  The  Adipo- 
Cellular  Tissue— 3.  The  Mus- 
cles—4.  The  Arteries— 5.  The 
Veins  and  Lymphatics — 6  The 
Nerves — 7.  The  Mucous  Mem- 
brane—8.  The  Skeleton,  99-101 

Sect.  9.  Olfactory  Region  (PI.  2.)         101 

1    The  Anterior  Apertures  of  the 

Nostrils,  102 

2.  The  Vault,  102 

3.  The  Internal  Walls,  105 

4.  The  Inferior  Wall  or  Floor,  105 

5.  The  External  Wall,  106 

6.  The  Posterior  Aperture  of  the 

Nasal  FOSSJB,  112 

A.  The  Arteries— B.  The  Veins— 
C.  The  Lymphatics — D.  The  Nerves,  113 


Sect.  10.  Buccal   Cavity  or  Region, 

85  (PI.  3.)  114 
85 

86  The  Palatine  Vault,  114 
86 

87  CONSTITUENT    PARTS. 

88 

89         1.  The  Mucous  Membrane — 

89  2.    The    Submucous    Tissue— 

89  3.  The  Arteries— 4  The  Veins— 

89  5.    The    Lymphatics  —  6.    The 
Nerves— 7.  The  Skeleton,  114-15 

90  The  Circumference  of  the  Buccal 

Cavity,  116 

The  Inferior  Wall,  118 

80  PARTS    CONSTITUTING  THE    TONGUE. 

90 

91  1.  The  Membranous  Envelope,        118 

91  2.  The  Cellular  Tissue,  119 

92  3.  The  Proper  or  Fleshy  Tissue,  119 
92  4.  The  Arteries,  120 
92  5.  The  Veins,  120 
92  6.  The  Lymphatics,  121 


COKTENTS. 


XIX 


7.  The  Nerves, 

8.  The  Skeleton, 

The  Isthmus  of  the  Throat, 


121  7.  The  Lymphatics, 

122  8.  The  Nerves, 
124      9.  The  Skeleton, 


194 
194 
198 


Sect.  11.  Pharyngeal  Region  or  Cav- 
ity, 128 

1.  The  Anterior  part,  129 

2.  The  Posterior  Wall,  131 

3.  The  Lateral  Walls,  131 

4.  The  Superior  Extremity  or  Vault 

of  the  Pharynx,  133 

5.  The  Inferior  Extremity,  134 


ARTICLE  II.    POSTERIOR  PART  OF 
THE  NECK. 

CONSTITUENT  PARTS. 


1.  The  Skin,  203 

2.  The  Subcutaneous  Cellular  Layer,  204 

3.  The  Aponeurosis,  204 

4.  The  Muscles,  205 

5.  The  Arteries,  208 
CHAPTER  II.     OF  THE  NECK,  135    6.  The  Veins,  209 

7.  The  Lymphatics,  210 

8.  The  Nerves,"  210 

9.  The  Skeleton,  211 


ARTICLE  I.  ANTERIOR  PORTION  OF 

THE  NECK,  135 


Sect.  1  Supra-Hyoideal  Region,  136 

CONSTITUENT    PARTS. 

1.  The  Skin,  136 

2.  The  Sub-cutaneous  Layer,  136 

3.  The  Aponeurosis,  137 

4.  The  Muscles,  138 

5.  The  Arteries,  142 

6.  The  Veins,  144 

7.  The  Lymphatic  Glands,  144 

8.  The  Submaxillary  Gland,  145 

9.  The  Nerves,  147 

10.  The  Cellular  Tissue,  148 

11.  The  Skeleton,  148 

Sect.  2.  Infra-Hyoideal  Region, 

(PI.  4.)  150 

CONSTITUENT    PARTS. 

1.  The  Skin,  151 

2.  The  Subcutaneous  Layer,  151 

3.  The  Aponeurosis,  151 

4.  The  Muscles,  152 

5.  The  arteries,  156 

6.  The  Veins,  162 

7.  The  Lymphatics,  165 

8.  The  Nerves,  166 

9.  The  Larynx  and  Trachea-Arte- 

na,  169 

10.  The  (Esophagus,  178 

11.  The  Skeleton,  179 

Sect.   3.     Supra-  Clavicular    Region, 

(PI.  5.)  179 

CONSTITUENT    PARTS. 

1.  The  Skin,  180 

2.  The  Subcutaneus  Layer,  180 

3.  The  Aponeurosis,  181 

4.  The  Muscles,  182 

5.  The  Arteries.  185 

6.  The  Veins,  190 


CHAPTER  III.  OF  THE  THORA- 
CIC EXTREMITIES,  217 

ARTICLE  I.  OF  THE  SHOULDER,  218 

Sect.  1.  Thoraco-Humeral,  Sub- Clav- 
icular or  Jlxillary  Region,  218 

CONSTITUENT    PARTS. 

1.  The  Skin,  219 

2.  The  Subcutaneous  Layer,  219 

3.  The  Aponeurosis,  220 

4.  The  Muscles,  221 

5.  The  Arteries,  226 

6.  The  Veins,  231 

7.  The  Lymphatics,  233 

8.  The  Nerves,  235 

9.  The  Skeleton,  233 

Sect.  2.  Posterior  Region  of  the  Shoul- 
der or  Scapulary  properly  cal- 
led, 243 

CONSTITUENT    PARTS. 

1.  The  Skin,  244 

2.  The  Subcutaneous  Layer,  244 

3.  The  Aponeurosis,  245 

4.  The  Muscles,  246 

5.  The  Arteries,  249 

6.  The  Veins,  251 

7.  The  Lymphatics,  251 

8.  The  Nerves,  251 

9.  The  Skeleton,  252 

ARTICLE  II.  OF  THE  ARM,  260 

Sect.  1.  Anterior  Brachial  Region,  260 


CONSTITUENT    PARTS. 


1.  The  Skin, 

2.  The  Subcutaneous  Layer, 

3.  The  Aponeurosis, 


261 
262 


CONTENTS. 


4.  The  Muscles, 

5.  The  Arteries, 

6.  The  Veins, 

7.  The  Lymphatics, 

8.  The  Nerves, 

9.  The  Skeleton, 


262 
264 
267 
268 
269 
270 


Sect.  2.  Posterior  Brachial  Region,  270 

CONSTITUENT    PARTS. 

1.  The  Skin,  271 

2.  The  Subcutaneous  Layer,  271 

3.  The  Aponeurosis,  271 

4.  The  Muscles,  272 

5.  The  Arteries,  273 

6.  The  Veins,  273 

7.  The  Lymphatics,  274 

8.  The  Nerves,  274 

9.  The  Skeleton,  274 

ARTICLE  III.  OF  THE  ELBOW,  275 

Sect.  1.  Anterior  Region  of  the  Elbow, 
or  simply  the  Fold  of  the  Arm, 

(PI.  6)  275 

CONSTITUENT    PARTS. 

1.  The  Skin,  276 

3.  The  Subcutaneous  Layer,  276 

3.  The  Aponeurosis,  276 

4.  The  Muscles,  278 

5.  The  Arteries,  282 

6.  The  Veins,  286 

7.  The  Lymphatics,  294 

8.  The  Nerves,  294 

9.  The  Skeleton,  296 

Sect.  2.  Posterior  Region  of  the  El- 
bow, or  Elbow  properly  called,  298 

CONSTITUENT    PARTS. 

1.  The  Skin,  299 

2.  The  Subcutaneous  Layer,  299 

3.  The  Aponeurosis,  300 

4.  The  Muscles,  301 

5.  The  Arteries,  302 

6.  The  Veins,  302 
1.  The  Lymphatics,  303 

8.  The  Nerves,  303 

9.  The  Skeleton,  304 

ARTICLE  IV. — OF  THE  FORE-ARM,  307 
Sect.  1.  Anterior  or  Palmar  Region,    307 

CONSTITUENT    PARTS. 

J.  The  Skin,  308 

•2.  The  Subcutaneous  Layer,  308 

3.  The  Aponeurosis,  308 

4.  The  Muscles,  309 
r>.  The  Arteries  310 


6.  The  Veins,  313 

7.  The  Lymphatics,  315 

8.  The  Nerves,  315 

9.  The  Skeleton,  316 

Sect.  2.  Posterior  Anti-Brachial  Re- 
gion, 317 

CONSTITUENT    PARTS. 

1.  The  Skin,  317 

2.  The  Subcutaneous  Layer,  317 

3.  The  Aponeurosis,  318 

4.  The  Muscles,  318 

5.  The  Arteries,  321 

6.  The  Veins,  321 

7.  The  Lymphatics,  321 

8.  The  Nerves,  322 

9.  The  Skeleton,  322 

Sect.  3.  Borders  of  the  Fore- Arm,        326 

ARTICLE  V.  OF  THE  WRIST.  327 

Sect.  1.  Anterior  Region,  327 

CONSTITUENT    PARTS. 

1.  The  Skin,  328 

2.  The  Subcutaneous  Layer,  328 

3.  The  Aponeurosis,  329 

4.  The  Muscles,  330 

5.  The  Arteries,  332 
6    The  Veins,  333 
7.  The  Lymphatics,  333 
8    The  Nerves,  334 
9.  The  Skeleton,  334 

Sect.  2.  Dorsal,  or  Posterior  Region  of 

the  Wrist,  336 

CONSTITUENT    PARTS. 

1.  The  Skin,  337 

2-  The  Subcutaneous  Layer,  337 

3.  The  Aponeurosis,  337 

4.  The  Muscles,  338 

5.  The  Arteries,  339 

6.  The  Veins,  340 

7.  The  Lymphatics,  340 

8.  The  Nerves,  340 

9.  The  Skeleton,  341 

ARTICLE  VI.— OP  THE  HAND.  345 

Sect.  I.  Palmar  Region,  34,r. 

CONSTITUENT    PARTS. 

1.  The  Skin,  346 

2.  The  Superficial  Layer.  347 

3.  The  Aponeurosis,  347 

4.  The  Muscles,  348 

5.  The  Arteries,  .350 

6.  The  Veins.  352 


CONTENTS. 


XXI 


7.  The  Lymphatics,  352 

8.  The  Nerves, 

9.  The  Skeleton,  353 

Sect.  2.  Dorsal  Region,  354 

CONSTITUENT    PARTS. 

1.  The  Skin,  354 

2.  The  Subcutaneous  Layer,  355 

3.  The  Aponeurosis,  355 

4.  The  Tendons  and  Muscles,  355 

5.  The  Arteries,  357 

6.  The  Veins,  357 

7.  The  Lymphatics,  357 , 

8.  The  Nerves,  358 

9.  The  Skeleton,  358 

ARTICLE  VII. — OF  THE  FINGERS,  362 

Sect .  1 .  Palmar  Region  of  the  Fin- 

-    gers,  362 

CONSTITUENT    PARTS* 

1.  The  Skin,  863 

2.  The  Subcutaneous  Layer,  363 

3.  The  Tendinous  Sheaths,  365 

4.  The  Tendons,  366 

5.  The  Arteries,  367 

6.  The  Veins,  368 

7.  The  Lymphatics,  368 

8.  The  Nerves,  368 

9.  The  Skeleton,  369 


4.  The  Muscles, 

5.  The  Arteries, 

6.  The  Veins, 

7    The  Lymphatics 
8.  The  Nerves, 
9    The  Skeleton, 

Sect.  2.  Posterior  Region, 

CONSTITUENT   PARTS. 

1.  The  Skin, 

2.  The  Subcutaneous  Layer, 

3.  The  Aponeurosis, 

4.  The  Muscles, 

5.  The  Arteries, 

6.  The  Veins, 

7.  The  Lymphatics, 

8.  The  Nerves 

9.  The  Skeleton, 

Sect.  3.  Costal  Region, 

CONSTITUENT    PARTS. 

1.  The  Skin, 

2.  The  Subcutaneous  Layer, 

3.  The  Aponeurosis, 

4.  The  Muscles, 

5.  The  Arteries, 

6.  The  Veins, 

7.  The  Lymphatics, 

8.  The  Nerves, 

9.  The  Skeleton, 


Sect.  2.  Dona/  Aspect  of  the  Fingers,  370     Sect.  4.  Mammary  Region, 


CONSTITUENT    PARTS. 

1.  The  Skin,  370 

2.  The  Subcutaneous  Layer,  371 

3.  The  Aponeurosis,  371 

4.  The  Tendons,  372 

5.  The  Arteries,  372 

6.  The  Veins,  372 

7.  The  Lymphatics,  $73 

8.  The  Nerves,  373 

9.  The  Skeleton,  373 

CHAPTER.  IV.  OF  THE  CHEST,  377 
ARTICLE.  I.  OF  THE  THORAX. 


CONSTITUENT   PARTS. 

1.  The  Skin, 

2.  The  Subcutaneous  Layer, 
3    The  Arteries, 

4.  The  Veins, 

5    The  Lymphatics, 

6.  The  Nerves, 

7    The  Mammary  Glan^, 

8.  The  Lactiferous  Vessels, 

ARTICLE.  I.  OF  THE  INTERIOR  OF 

THE  THORAX, 


380 
382 
383 
384 
384 
385 

391 


392 
392 
393 
394 
396 
397 
397 
398 
398 

403 


403 
404 
404 
404 
406 
408 
408 
409 
409 

414 


415 
416 
416 
417 
418 
418 
418 
420 


378     Sect.  1    Median  Septum,  or  Medi-  )    42] 

astinal  Region, 
Sect  1.  Anterior  or  Sternal  Region.    378 

Sect.  2.  Pectoral  Cavities,  434 

CON   TITUES-T    PARTS. 

Sect.  3.  Base  of  the  Thorax,  440 

1.  The  Skin,  379 

2.  The  Subcutaneous  Layer,  379     Sect.  4.  Summit  of  the  Thorax,  442 

3.  The  Aponeurosie,  380 


ERRATA. 

Page  3,  line  S,  for  "at  its  central ,"  read  "in  its  middle." 

"      7,     "  24,  for  "aponeurosis,"  read  "aponeuroses." 

"    29,     "    8,  for  "membrani,"  read  "membrana." 

"    37,     «    4,  for  "the  slide,"  read  "slide." 

"    45,  last  line,  for  "eye-lids,"  read  eye-lashes." 
•   «•    80,  line  23,  for  "a  deep  branch,"  read  "and  a  deep  branch." 

"  136,     "    4,  for  "cornea,"  read  cornua." 

"  202,     "  15,  for  "porrigo,"  read  "prurigo." 

"  225,  "  4,  for  "The  Subscapularis.  The  anterior,"  read  "The  Subscapii-, 
laris,  the  anterior." 

Jt  277,  lines  6  &  7,  for  "and  where  it  dips,  the  deep-seated  sheet,  is  also  ap- 
plied to  it,  down  into  the  external  furrow,"  read  "and 
it  is  also  applied  to  the  deep  sheet,  where  it  dips 
down  into  the  external  furrow." 

"  277,  line  38,  for  "fibrous  sheet  sheath,"  read  "fibrous  sheet  (sheath)" 


SURGICAL   ANATOMY. 


CHAPTER  I. 
OF  THE  HEAD. 

THE  head  is  composed  of  the  cranium  and  face. 

ART.  I.    OF   THE    CRANIUM. 

This  part  of  the  head  may  be  divided  into  three  regions  on 
each  side  of  the  median  line.  These  regions  will  be  circum- 
scribed by  arbitrary  lines,  drawn  from  natural  prominences,  and 
designated  by  the  name  of  the  principal  bone  corresponding  to 
them ;  as,  for  example,  the  frontal,  temporo-parietal  and  occipi- 
tal regions. 

Sect.  1.  The  Frontal  Region. 

It  is  triangular,  and  bounded,  inferiorly,  by  a  curved  line  ex- 
tending above  the  eyebrow  from  one  of  the  orbital  processes  of 
the  os  frontis  to  the  other  ;  internally,  by  the  median  line  which 
separates  it  from  its  fellow  on  the  opposite  side  ;  and  externally, 
by  a  third  line  which  ascends  from  the  external  orbital  process, 


2  OF    THE    HEAD. 

in  the  course  of  the  fronto-parietal   suture,  to  the  origin  of  the 
sagittal  suture. 

The  surface  of  this  region  presents,  inferiorly,  a  transverse 
furrow  of  greater  or  less  breadth  ;  in  the  middle,  a  more  or  less 
prominent  bump,  constituting  the  frontal  groove  and  protube- 
rance ;  internally,  the  frontal  vein  and  some  one  of  its  branch- 
es ;  and  superiorly,  the  hair,  which  descends  more  or  less  in  dif- 
ferent individuals. 


COMPONENT    PARTS. 

i.  The  Shin. 

This  is  thin  and  smooth  in  children  and  young  persons  of  both 
sexes  ;  in  adults,  and  old  people  especially,  we  sometimes  ob- 
serve numerous  transverse  wrinkles  in  the  lower  half  of  this  re- 
gion. Upwards  and  outwards,  where  it  usually  serves  for  the 
implantation  of  the  hairs,  it  is  thicker  and  destitute  of  wrinkles. 
In  this  last  direction  it  contains  many  sebaceous  follicles.  The 
hairs  generally  pierce  the  skin  obliquely  forwards  or  outwards, 
whence  their  tendency  to  follow  one  or  the  other  of  these  direc- 
tions in  descending  upon  the  forehead. 

n.  The  Cellulo-adipose  Layer. 

Situated  between  the  frontal  muscle  and  skin  it  is  generally 
very  thin  ;  the  cellular  tissue  which  composes  it  is  dense  and 
compact  ;  the  adipose  cells  are  very  minute  and  in  close  con- 
tact ;  externally,  near  the  temple,  they  are  larger,  less  intimately 
connected,  and  sometimes  form  a  layer  of  considerable  thick- 
ness. The  intimate  union  of  this  layer  with  the  two  strata  be- 
tween which  it  is  interposed,  explains  the  reason  why  lesions 
of  the  skin  here  are  more  liable  to  produce  inflammations  of  the 
erysipelatous  character  ;  for  we  may  readily  conceive  that  it 
would  be  difficult  for  pus  to  collect  in  the  form  of  abscess  in  a 
tissue  so  compact.  For  the  same  reason  also,  when  purulent  or 
sanguineous  tumours  form  in  this  region,  they  are  always  cir- 
cumscribed, globular,  or  more  or  less  flattened  ;  finally,  it  is  in 


Or    THE    HEAD. 

this  stratum  that  encysted  tumours  (lupia)  or  tannes,*  which  are 
merely  the  follicles  enormously  dilated  and  filled  with  a  concrete 
sebaceous  matter  are  developed  :  the  roots  of  the  hairs  are 
likewise  situated  in  it. 

HI.  The  Muscles  and  Aponeurosis. 

The  muscles  are,  inferiorly,  a  very  small  portion  of  the  or- 
bicularis  palpebrarum  ;  above  this,  the  frontalis,  which  is  thickest 
at  its  central,  and  especially  its  inferior  part,  where  it  covers  the 
whole  breadth  of  the  bone ;  its  fibres  are  parallel,  and,  on  con- 
tracting, wrinkle  the  forehead.  It  seems  as  if  these  muscles 
were  developed  upon  the  external  surface  of  the  epi  cranial 
aponeurosis,  which  is  thin  and  cellular  beneath  them ;  superiorly 
and  posteriorly,  this  aponeurosis  alone  exists,  and  is  there  much 
stronger  and  decidedly  fibrous.  It  is  difficult  to  separate  these 
parts  from  the  subcutaneous  stratum:  to  the  pericranium,  on 
the  contrary,  they  are  but  loosely  connected  by  a  lamellated 
tissue,  especially  at  the  outer  and  inferior  part  of  the  region. 
This  cellular  tissue  encloses  a  great  number  of  adipose  vesicles, 
in  consequence  of  which  disposition  it  happens  that,  when  pus 
or  other  fluids  are  secreted  into  the  space  between  these  two 
layers,  they  become  extensively  diffused  instead  of  forming 
distinct  tumours.  It  is  necessary  to  be  aware  of  this  circum- 
stance, in  order  to  determine  the  nature  and  danger  of  diseases 
situated  in  the  frontal  region. 

iv.    The  Pericranium. 

It  presents  nothing  of  importance ;  we  have  just  noticed  its 
relations  with  the  musculo-aponeurotic  layer ;  it  is  connected 
to  the  bones  by  a  lamellated  rather  than  a  filamentous  cellular 
tissue,  so  that  it  can  be  easily  separated  from  the  cranium,  ex- 
cept at  the  sutures. 

v.   The  Arteries. 
These  are  branches  of  the  supra-orbital,  the  trunk  of  which 

'  Acne. 


Or    THE    HEAD. 

was  at  first  situated  between  the  orbicularis  and  frontalis 
muscles ;  they  afterwards  creep  in  the  subcutaneous  layer.  The 
anterior  branch  of  the  superficial  temporal  also  runs  through 
it,  and  forms  numerous  anastomoses  with  the  preceding.  The 
tissue  which  envelopes  these  vessels  is  so  compact,  that  it  is 
difficult  to  seize  them  with  an  instrument  in  order  to  tie  them, 
therefore  compression  is  generally  preferred  to  the  ligature.  If, 
however,  in  consequence  of  acute  pain  or  inflammation,  we  can 
only  employ  the  latter,  we  will  succeed  better  with  a  tenaculum 
than  the  forceps. 

In  the  pericranium  we  only  find  capillary  twigs  of  the  deep- 
seated  temporals. 

vi.  The  Veins. 

Near  the  median  line  we  generally  find  the  frontal  vein,  which 
is  sometimes  wanting,  and,  at  other  times,  as  we  have  seen  it 
in  two  subjects,  double  or  triple ;  it  is  often  very  large,  espe- 
cially in  old  people.  The  ancients  frequently  drew  blood  from 
it  in  affections  of  the  head,  and  we  think  that  this  bleeding  is  at 
present  too  much  neglected.  This  vein,  in  fact,  returns  the 
blood  from  the  anterior  half  of  the  cranium  to  the  root  of  the 
nose  ;  therefore,  it  is  evident,  that  by  opening  it  we  would 
immediately  disgorge  the  vessels  of  the  hairy  scalp.  This  vessel 
is  situated  between  the  skin  and  the  cellulo-adipose  layer,  and 
is  not  accompanied  by  any  artery ;  consequently  we  may  easily 
open  it  without  danger  of  wounding  any  important  organ.  The 
other  veins  accompany  the  arterial  branches  and  present  nothing 
remarkable,  unless  it  is  that  some  of  them  pass  through  the 
frontal  and  fronto-parietal  sutures  to  the  longitudinal  sinus  or 
dura  mater.  These  branches  are  generally  small  and  destitute 
of  valves :  hence  they  might  serve  for  abstracting  blood  from 
the  interior  of  the  cranium,  if  cupping-glasses,  or  leeches,  were 
applied  over  the  points  of  skin  corresponding  to  them :  it  is  for 
this  reason  that  Santorini  calls  them  emissary  veins. 

vir.  The  Lymphatic  Vessels. 
They  are  few  in  number,  and  but  imperfectly  known.     They 


OF   THE    HEAD.  O 

pass  into  the  glands  of  the  parotideal  region,  and  it  is  for  this 
reason  that  diseases  of  the  frontal  region  sometimes  occasion 
tumefaction  of  the  lymphatic  glands  in  the  vicinity  of  the  ear ; 
whether  arising  from  the  transmission  of  irritating  fluids  ab- 
sorbed at  the  diseased  part,  or  continuous  sympathy,  <£c. 

vni.   TJie  Nerves. 

They  are  derived  from  the  fifth  pair.  As  the  internal  fron- 
tal comes  out  from  the  orbit  it  is  at  first  situated  between  the 
pericranium  and  corrugator  supercilii  muscle;  it  afterwards 
perforates  the  epicranjal  aponeurosis,  in  order  to  ramify  in  the 
fibres  of  the  frontalis,  and,  more  especially,  in  the  internal  half 
of  this  muscle.  The  filaments  of  the  superciliary  or  external 
frontal  nerve,  on  the  contrary,  are  distributed  to  the  aponeurosis 
and  even  to  the  pericranium,  which  gives  them  a  flattened  form 
and  much  firmness. 

These  nerves  are  spread  out,  for  the  most  part,  in  the  external 
part  of  the  region,  and  anastomose,  near  the  external  orbital 
process,  with  some  filaments  of  the  facial ;  more  posteriorly, 
they  unite  with  the  superficial  temporal  given  off  by  the  auricu- 
lar branch  of  the  inferior  maxillary. 

The  nerves  of  the  ganglionic  system  are  blended  with  the 
arterial  tunics,  and  are  of  no  importance  in  surgery. 

ix.  The  Skeleton* 

It  comprises  only  one  of  the  halves  of  the  os  frontis.  This 
bone  presents :  externally,  the  external  orbital  process,  which, 
on  account  of  its  prominence,  is  very  much  exposed  to  fracture : 
from  it  commences  the  semi-circular  line  of  the  temporal  fossa. 
At  this  point  we  sometimes  find  a  veinous  canal :  from  which 
circumstance,  a  perforation  of  the  cranium  here  might  occasion 

*  The  term  squelette  (skeleton)  is  made  use  of  by  Mr.  Velpeau  to  signify  the 
frame  work  of  each  particular  region,  and  therefore  comprises,  in  several  regions, 
not  only  the  bones,  but  also  the  periosteum,  ligaments,  cartilages,  &c.  As  no 
other  word  equally  comprehensive  and  appropriate  could  have  been  substituted 
for  it,  it  has  been  retained  in  the  translation,  notwithstanding  English  and  Ameri- 
can anatomists  limit  it?  application  to  the  frame  work  of  the  whole  system. — 
Transl. 


6  OP   THE    HEAD. 

a  considerable  discharge  of  blood  without  any  injury  of  the 
vessels  of  the  dura  mater.  Internally,  we  observe  the  nasal  pro- 
tuberance, which  is  more  prominent  in  man,  and  in  old  age,  than 
in  women  and  children ;  also,  in  the  latter  the  forehead  is  al- 
most flat,  and,  generally,  the  root  of  the  nose  appears  less  de- 
pressed. This  protuberance  corresponds,  anteriorly,  to  the  head 
of  the  eyebrow ;  posteriorly,  it  forms  the  anterior  wall  of  the 
frontal  sinus,  cavities  produced  by  the  separation  of  the  tables 
of  the  bone,  and  with  which  it  is  of  importance  to  be  well 
acquainted ;  for  the  outer  table  alone  may  be  fractured,  and  be 
mistaken  for  a  depression  of  the  cranial  arch.  As  these  sinuses 
are  lined  by  a  prolongation  of  the  internal  membrane  of  the 
nostrils,  .puriform  mucus,  &c.,  may  be  discharged  from  the 
nasal  cavities  externally  through  an  accidental  perforation  of 
these  sinuses,  and  deceive  inattentive  persons,  inducing  them  to 
believe  that  this  matter  comes  from  within  the  cranium.*  Such 
a  mistake  may  likewise  occur  without  any  external  opening  of 
the  sinus,  where  the  liquid  flows  into  the  nose  with  the  charac- 
ters of  pus  from  the  cerebral  substance.  In  the  first  case  also, 
the  air,  by  penetrating  into  the  sinus,  may  communicate  to  the 
mucous  membrane  movements  analogous  to  those  of  the  brain, 
and  thereby  encourage  the  error,  f  This  membrane,  also,  from 
its  communication  with  the  nasal  cavities  and  its  secretion,  is 
considered  as  the  cause  of  fistulae  which  sometimes  occur  in 
this  place  in  consequence  of  wounds  or  other  diseases  which 
have  perforated  the  anterior  wrall  of  this  sinus ; — fistulae  which 
are  difficult  to  cure,  but  not  incurable,  since  Professsor  Dupuy- 
tren  says  that  he  has  seen  many  of  them  cicatrise.  From  the 
unequal  separation  of  the  walls  of  the  frontal  sinus,  it  follows 
that  we  ought  to  avoid,  if  possible,  trephining  in  this  situation, 
because  the  crown  of  the  instrument  might  lacerate  the  mem- 
branes of  the  brain  in  some  points,  before  the  section  of  the 
bone  is  completed.  In  an  extreme  case,  however,  it  would  be 
possible  to  remove  the  portion  of  bone  without  injuring  the 
membranes,  provided  we  use  a  trephine  with  a  large  crown,  for 
sawing  through  the  external  table,  and  a  smalller  one  for  the 
internal,  as  has  been  advised  by  Professor  Boyer  and  M.  Lisfranc. 

*  Marechal.  f  M.  Boyer. 


OF   THE    HEAD.  i 

The  frontal  sinuses  sometimes  extend  as  far  as  the  external 
orbital  process,  and  even  as  high  as  the  os  parietale,  as  observed 
by  Ruysch,  and  twice  by  us ; — this  we  should  likewise  bear  in 
mind  when  called  upon  to  trephine  this  bone.  This  latter  dis- 
position would  prevent  us  from  estimating  the  volume  of  the 
anterior  parts  of  the  brain  from  an  external  examination  of  the 
cranium.  When  pus  or  other  fluids  accumulate,  or  tumours 
form  in  the  frontal  sinuses,  the  posterior  wall  of  these  cavities 
being  thinner  than  the  anterior,  it  wjll  yield  first  and  thereby 
give  rise  to  cerebral  compression,  &c.  These  cavities  are 
wanting  in  certain  individuals,  as  is  said  to  be  the  case  in  the 
(camus)  flat-nosed. 

Above  the  preceding  prominences,  the  os  frontis  presents  a 
depression  which  corresponds  to  the  cutaneous  groove  of  the  fore- 
head ;  still  higher,  the  frontal  protuberance,  which  is  more  or  less 
prominent  in  different  subjects,  which  disposition  may  be  owing 
to"a  greater  degree  of  convexity  of  the  bone  at  this  part  or  in- 
creased thickness.  In  the  latter  case,  after  having  been  very 
prominent,  it  may  become  depressed  in  old  age  from  absorption 
of  the  diploe. 

In  consequence  of  this  structure  we  cannot  penetrate  the  cra- 
nium by  the  frontal  region  without  traversing  the  different  layers 
which  have  just  been  pointed  out,  and  of  which  the  following  is 
the  order  of  superposition : 

1st.  The  skin ;  2d,  the  cellulo-adipose  layer,  which  is  dense 
and  encloses  the  principal  vessels ;  3d,  the  muscles  and  aponeu- 
roses,  the  internal  frontal  nerve,  and  some  branches  of  the  super- 
ciliary ;  4th,  the  pericranium  and  some  filaments  of  the  latter 
nerve  ;  5th,  the  os  frontis. 

Sect.  2.  Temporo-Parietal  Region. 

It  is  of  a  quadrangular  form,  and  bounded,  inferiorly,  by  a  line 
drawn  from  the  external  orbital  process  along  the  superior  bor- 
der of  the  zygomatic  arch,  and  terminating  at  the  fore  part  of  the 
mastoid  process ;  superiorly,  by  the  analogous  region  of  the  op- 
posite side ;  anteriorly,  by  the  external  boundary  of  the  frontal 
region ;  and,  posteriorly,  by  a  line  extending  from  the  anterior 


8  OF    THE    HEAD. 

part  of  the  mastoid  process  to  the  junction  of  the  sagittal  with 
the  lambdoidal  suture. 

Upon  its  surface  we  observe,  between  the  ear  and  frontal  re- 
gion, above  the  zygoma,  sometimes  a  convexity,  at  others  a  con- 
cavity, according  to  the  embonpoint  of  the  individual  and  the 
volume  of  the  temporal  muscle.  Above  the  temporal  fossa  we 
find  a  broad  and  regularly  circumscribed  prominence :  this  is  the 
parietal  protuberance. 

• 

CONSTITUENT   PARTS. 

i.  The  Skin. 

In  the  inferior  part  of  the  region  this  membrane  is  very  thin, 
extensible,  and  but  slightly  adherent  to  the  subjacent  tissues. 
Anterior  to  the  auricle,  and  in  approximating  the  external  orbital 
process,  it  becomes  a  little  thicker,  and  is  more  intimately 
connected  with  the  adipose  layer ;  thus  far,  it  is  not  generally 
covered  with  hair.  As  we  trace  it  backwards  and  upwards,  it 
gradually  becomes  thicker,  and  assumes  the  same  characters 
with  that  of  the  upper  part  of  the  frontal  region.  The  hairs 
which  cover  it  are  implanted  into  it  obliquely,  so  that  those  in 
the  centre  descend  towards  the  ear,  the  anterior  to  the  forehead, 
and  the  posterior  towards  the  neck.  There  are  a  great  number 
of  follicles  at  the  roots  of  these  hairs,  which  last  turn  gray  sooner 
in  this  region  than  in  any  other :  whence  the  name  "  temporal 

ii.  The  Cellulo-adiposc  Layer. 

It  is  generally  thin,  but  becomes  thicker  as  it  descends :  it  lies 
upon  a  stronger  layer  of  a  fibre-cellular  nature.  The  three  small 
auricular  muscles  are  included  between  the  plates  of  the  latter, 
or  rest  upon  its  external  surface,  and  it  is  thicker  behind  than 
before.  We  may  consider  it  as  the  fascia  superficialis  of  the 
temporal  region,  and  the  superficial  temporal  vessels  and  nerves 
creep  through  its  tissue.  As  it  passes  under  the  hairy  scalp,  it 
becomes  blended  with  the  dense  and  compact  texture  which  sep- 
arates the  integuments  from  the  epicranial  aponeurosis. 


OF    THE    HEAD.  _   U 

HI.  The  Epicranial  Aponeurosis. 

Above  the  temporal  fossa  it  is  strong,  thick,  firm  and  unyield- 
ing ;  its  relations  with  the  pericranium  and  skin  are  the  same  as 
in  the  frontal  region ;  and,  consequently,  the  same  surgical  re- 
marks are  applicable  to  it.  Surgeons  formerly  supposed  that 
this  fibrous  sheet  was  possessed  of  exquisite  sensibility,  and  there- 
fore attributed  to  it  much  of  the  severity  of  the  symptoms  which 
attend  upon  wounds  of  the  head.  Be  this  as  it  may,  its  dense 
and  compact  texture  prevents  morbid  fluids  from  accumulating 
beneath  it  in  the  form  of  abscesses,  hence  they  promptly  dif- 
fuse themselves  and  produce  denudation  and  even  necrosis  of 
the  bone.  When  the  cellular  tissue  beneath  this  becomes  in- 
flamed, the  resistance  which  this  aponeurosis  affords  to  the  subja- 
cent phlegmonous  tumefaction,  accounts  for  the  acute  pains  which 
then  manifest  themselves,  and  calls  for  the  different  incisions 
recommended  in  such  cases. 

Over  the  temporal  fossa  the  aponeurosis  is  thinner ;  upon  the 
zygomatic  arch  it  is  blended  with  the  fascia  superficialis,  and 
passes  into  the  parotideal  region ;  it  supports  the  branches  of  the 
superficial  temporal  and  auricular  arteries,  &c.  Downwards 
and  forwards,  it  is  perforated  by  the  superficial  temporal  nerve 
of  the  fifth  pair,  and  is,  in  general,  somewhat  firmly  united  to  the 
temporal  aponeurosis,  although  inferiorly  it  is  separated  from  it 
by  some  adipose  cells.  About  an  inch  behind  the  orbit  and 
above  the  zygomatic  arch,  these  two  lamina?  are  fixed  to  the  tem- 
poral aponeurosis  by  a  kind  of  pedicle,  in  which  are  one  or  more 
nervous  filaments,  and  some  arterial  and  venous  twigs  which 
come  from  the  zygomatic  fossa. 

iv.  The  Temporal  Aponeurosis. 

This  fascia  is  of  an  oval  form,  and  is  attached  to  the  whole  of 
the  semicircular  line  of  the  temporal  fossa :  from  the  superior  and 
posterior  five-sixths  of  its  internal  surface  muscular  fibres  originate ; 
but  the  anterior  and  inferior  sixth  of  its  extent  is  separated  from 
the  muscle  by  a  soft  adipose  tissue.  Here,  this  membrane  is  bifo- 
liate, and  its  two  sheets  are  continuous  with  the  periosteum 
covering  the  internal  and  external  surfaces  of  the  zygomatic  arch. 

2 


10  01'    THE    HEAD. 

These  two  laminae  are  separated  by  fat,  which  gives  a  promin- 
ence to  the  temporal  region  proportionate  to  its  abundance  ;  on 
the  contrary,  where  this  fat  is  absent  there  is  a  correspondent  de- 
pression. 

Inflammation  is  frequently  excited  in  this  adipo-cellular  tissue, 
and  when  matter  forms  in  consequence,  we  must  give  it  an  early 
exit,  otherwise  it  will  perforate  the  internal  sheet  of  the  aponeu- 
rosis,  which  is  thinner  than  the  external,  and  make  its  way  into 
the  zygomatic  fossa.  Anteriorly,  towards  the  point  where  these 
two  laminae  unite,  they  are  perforated  by  the  pedicle  just  men- 
tioned, when  on  the  epicranial  aponeurosis. 

v.  The  Muscles. 

The  frontalis  muscle  sometimes  advances  a  little  into  the  supe- 
rior part  of  this  region  ;  the  three  auriculares  have  already  been 
noticed  ;  the  temporalis  remains  to  be  spoken  of.  As  the  fibres 
of  this  muscle  converge  towards  the  central  tendon  which  em- 
braces the  coronoid  process  of  the  inferior  maxillary  bone,  it  is 
generally  recommended,  when  about  to  apply  the  trephine,  to 
make  the  incision  in  the  form  of  the  letter  V,  in  order  that  their 
action  may  be  preserved.  This  advice  cannot  be  attended  with 
danger,  but  the  idea  upon  which  it  is  founded  does  not  seem  to  be 
correct ;  for,  whether  the  fibres  are  cut  transversely  or  parallel  to 
their  axis,  a  similar  number,  as  the  fkp  must  be  raised,  will  be 
divided  ;  and,  as  we  know  that  fleshy  fibres,  when  once  incised, 
always  reunite  by  means  of  a  fibrous  cicatrix,  the  direction  of  the 
incision  can  then  make  but  little  difference. 

vi.  The  Arteries. 

We  must  examine  especially  the  superficial  temporal  and  its 
branches.  Its  trunk  is  situated  between  the  epicranial  aponeuro- 
ris  and  superficial  fascia,  and,  as  these  fibro-cellular  laminae  are  not 
very  compact,  if  the  artery  was  divided,  and  we  wished  to  tie  it 
in  the  temporal  portion  of  this  region,  we  would  not  experience 
the  same  difficulties  as  in  the  parietal  portion.  Above  the  zygo- 
matic arch,  the  superficial  temporal  artery  is  situated  about  two 
or  three  lines  anterior  to  the  auricle,  at  which  place  it  would  be 


OF    THE    HEAD. 


11 


very  easy  to  open,  or  apply  a  ligature  around  it,  if  considered  ne- 
cessary. It  is  also  useful  to  note  this  situation  in  order  to  avoid 
the  application  of  caustic,  moxa,  cups,  or  leeches  over  this  part, 
unless  particular  indications  demand  them,  and  to  take  all  proper 
precautions.  Perhaps  it  would  be  more  prudent  to  perform  arte- 
riotomy  a  little  higher  up,  because,  the  cellular  tissue  being  more 
abundant  here,  inflammation  would  be  more  liable  to  ensue  ;  com- 
pression would  also  be  less  immediate  and  more  painful,  on  ac- 
count of  the  aponeurosis  being  more  remote  from  the  bone,  and 
finally  on  account  of  the  proximity  of  the  meatus  auditorius  ex- 
ternus. 

The  anterior  branch  of  the  superficial  temporal  passes  to  anas- 
tomose with  the  frontal,  and  the  posterior  with  branches  of  the 
occipital ;  they  often  interosculate,  thereby  forming  a  complete 
net  work  which  is  always  covered  by  the  fascia  superficialis  and 
skin.  These  numerous  anastomoses  oblige  us  to  tie  or  compress 
both  extremities  of  the  divided  artery  in  order  to  arrest  the 
haemorrhage  effectually  ;  for  if  wre  obliterate  but  one  of  them,  the 
blood  will  continue  to  flow  from  the  other. 

We  likewise  find  in  this  region  the  middle  temporal,  which 
comes  off  from  the  trunk  of  the  preceding  on  a  level  with  the 
zygoma ;  it  immediately  perforates  the  external  sheet  of  the  tem- 
poral aponeurosis,  in  order  to  ramify  in  the  adipo-cellular  tissue 
which  separates  it  from  the  internal,  and  afterwards,  penetrating 
the  latter,  enters  into  the  substance  of  the  muscle,  where  it  inos- 
culates with  the  deep-seated  temporals. 

These  last,  arising  from  the  internal  maxillary,  distribute  their 
principal  branches  to  the  temporal  muscle  and  the  external  sur- 
face of  its  central  tendon  ;  the  others  are  applied  upon  the  bones, 
where  they  meet  with  certain  fissures,  in  which  they  become  im- 
bedded. The  inosculations  of  the  deep-seated  anterior  temporal 
with  twigs  wrhich  come  from  the  orbit,  may,  in  some  measure, 
account  for  the  pain  which  is  sometimes  experienced  in  the  tem- 
poral fossa  in  consequence  of  diseases  of  the  eye,  and  vice  versa. 

vn.  The  Veins. 
There  is  at  least  one  for  each  deep-seated  artery.     The  ante- 


OF    THE    HEAD. 

rior  branch  of  the  temporal  artery  has  none  when  the  frontal  vein 
exists.  In  this  region  we  find  a  very  large  emissary  vein  which 
comes  out  of  the  cranium  through  the  parietal  foramen.  We  will 
recur  to  this  when  we  come  to  speak  of  the  bones. 

vin.  T/te  Lymphatics. 

We  are  a  little  better  acquainted  with  these  vessels  than  with 
those  of  the  frontal  region ;  they  generally  accompany  the  arte- 
rial branches.  The  superficial  set  passes  into  the  glands  which 
surround  the  ear,  the  other  to  the  deep-seated  glands  of  the  neck  ; 
whence  certain  authors  have  supposed  that  an  engorgement  of 
the  subcutaneous  lymphatic  glands  indicated  disease  of  the  skin 
or  parts  external  to  the  temporal  aponeurosis,  whilst  deeper 
seated  affections  gave  rise  to  tumefaction  of  the  interrnuscular 
cervical  glands. 

ix.  The  Nerves. 

These  are  very  numerous,  but  of  little  importance  as  it  re- 
gards operations :  some  of  them  are  superficial,  the  others  deep- 
seated.  The  former  are  derived,  1st,  from  the  cervical  plexus, 
which  distributes  branches  to  the  skin  arid  subjacent  cellular  tis- 
sue ;  2d,  from  the  facial,  numerous  filaments  of  which  accom- 
pany the  arteries  in  the  fascia  superficialis,  and  anastomose  with 
the  supra-orbital  in  the  frontal  region  ;  3d,  from  the  auricular  of 
the  inferior  maxillary :  this  branch,  which  is  the  superficial  tem- 
poral, is  anterior,  and  follows  the  same  direction  with  the  fila- 
ments of  the  facial,  with  which  it  freely  inosculates. 

The  second  originate,  1st,  from  the  temporals  of  the  inferior 
maxillary,  and  the  temporal  filament  of  the  orbital  branch  of  the 
superior  maxillary;  2d,  in  the  parietal  portion  of  the  region, 
from  the  anastomotic  branches  of  the  frontal,  sub-occipital  and 
sub-mastoid.  From  this  simple  enumeration,  we  see  that  a  disease 
of  the  temple  may  give  rise  to  pain  in  all  parts  of  the  head,  and  be 
repeated  in  the  orbit,  jaws,  face,  ears,  neck,  etc.,  and  vice  versa. 

As  to  the  nerves  from  the  great  sympathetic,  they  can  only  be 
traced  upon  the  arteries,  and  their  study  is  of  no  surgical  im- 
portance. 


DP    THE    HEAD.  13 


x.  The  Skeleton. 

We  find  in  this  region  the  whole  of  the  squamous  portion  of 
the  temporal  bone,  the  temporal  part  of  the  great  ala  of  the 
sphenoid,  a  very  small  portion  of  the  os  frontis,  and  almost  the 
whole  of  the  parietal.  Sometimes  the  squamous  portion  of  the 
bone  is  convex  instead  of  being  plane  or  concave ;  whence  a 
greater  prominence  of  the  temple.  At  the  junction  of  the  sphe- 
noid with  the  frontal,  parietal,  and  temporal  bones,  we  find  the 
greatest  depth  of  the  temporal  fossa.  It  is  on  account  of  the  ' 
sutures  which  result  from  the  junction  of  these  different  bones, 
and  especially  because  the  Arteria  Meningea  Media  runs  through 
a  groove  in  the  internal  surface  of  the  anterior  and  inferior  parie- 
tal angle,  that  we  are  forbidden  to  apply  the  trephine  at  this  part. 
It  is  true  that  the  cases  which  would  require  a  perforation  of  the 
cranium  here  must  be  very  rare,  because  in  this  situation  the 
meninges  are  firmly  adherent  to  the  bones :  it  is  also  true  that 
the  operation  would  be  rendered  difficult  by  the  inequality  of 
the  surfaces  and  the  thickness  of  the  soft  parts ;  but  if  the  indi- 
cation is  positive,  the  situation  of  the  artery  should  not  deter  us ; 
for  even  if  the  artery  should  be  wounded  by  the  instrument,  it 
would  be  very  easy  to  compress  it.  The  tenuity  of  the  os  tem- 
poris  in  this  region,  sufficiently  explains  the  frequency  of  its  frac- 
tures. We  should  bear  in  mind  the  situation  and  appearance  of 
the  squamous  and  other  sutures,  in  order  that  we  may  avoid  mis- 
taking them  for  fissures,  an  error  committed  and  pointed  out  by 
Hippocrates,  and  not  unfrequently  since  his  time.  This  remark 
is  applicable  to  all  points  of  the  cranium. 

The  arched  form  of  the  parietal  bone  is  the  most  variable  as 
well  as  most  remarkable  appearance  of  the  skeleton  of  the  tem- 
poro-parietal  region.  Sometimes  the  parietal  protuberance 
scarcely  exists,  whilst  at  others  it  is  very  prominent.  In  some 
subjects  it  is  larger  on  one  side  than  the  other ;  hence  a  want  of 
symmetry  in  the  cranium.  This  irregular  conformation  is  not 
infrequent,  and  is  even  present  in  men  of  the  greatest  talent,  of 
which  the  celebrated  Bichat  and  the  learned  Beclard  have  afforded 
examples.  The  bone  is  sometimes  very  thick  at  this  point ;  so  that 
the  parietal  projection  does  not  always  indicate  an  increased 


14  OF    THE    11EAJJ. 

capacity  of  the  cranium.  Here,  senile  atrophy  most  frequently 
manifests  itself,  and  then,  instead  of  a  bump,  we  find  an  excava- 
tion. The  parietal  bone  has  sometimes  acquired  the  hardness  of 
ivory.* 

The  superficial  situation  of  this  bone  subjects  it  to  numerous 
diseases ;  nevertheless,  its  arched  form  renders  it  less  liable  to 
fractures  from  a  direct  cause,  than  it  would  otherwise  be.  In 
relation  to  the  application  of  the  trephine,  we  must  recollect  that 
the  greatest  thickness  of  the  parietal  bone  corresponds  to  its 
protuberance  ;  next,  to  the  posterior  and  superior  angle  ;  then,  to 
the  inferior  and  posterior ;  after  which  comes  the  superior  arid 
anterior ;  and  finally,  the  inferior  and  anterior  angle,  which  is  the 
thinnest.  Between  the  parietal  bump  and  sagittal  suture,  there 
are  one  or  more  foramina,  situated  nearer  the  posterior  than  the 
anterior  part.  These  foramina  communicate  with  the  venous 
canals  of  the  diploe,  or  with  the  sinuses  of  the  dura  mater,  and 
give  passage  to  emissary  veins  of  considerable  volume,  which  we 
have  before  referred  to.  It  is  by  these  veins  that  we  are  recom- 
mended to  disgorge  directly  the  sinuses,  meninges,  and  brain,  by 
applying  leeches,  etc.,  over  the  points  corresponding  to  these 
vessels.* 

The  order  of  superposition  in  the  temporal  portion  of  this 
region  is  as  follows:  1st,  the  skin;  2d,  the  cellulo-adipose  layer: 
3d,  the  fascia-superficialis,  beneath  which  are  the  superficial  ves- 
sels and  nerves ;  4th,  the  epicranial  aponeurosis,  separated  from 
the  preceding  by  nerves  and  vessels ;  5th,  the  temporal  aponeu- 
rosis ;  6th,  the  temporal  muscle ;  7th,  the  pericranium ;  8th,  the 
bones. 

In  the  parietal  portion  we  only  find,  1st,  the  skin ;  2d,  the 
fibro-adipose  layer,  which  encloses  the  nerves  and  vessels ;  3d,  the 
epicranial  aponeurosis ;  4th,  the  pericranium  :  and  5th,  the  bones. 

Sect.  3.     Occipital  Region. 

Its  figure  resembles  that  of  the  frontal  region :  that  is  to  say. 
supposing  it  to  be  flattened  out,  it  is  triangular.  Its  boundaries 
are,  anteriorly,  the  preceding  region ;  upon  the  median  line,  its 

*  M.  Portal. 


OF    THE    HEAD.  15 

fellow  of  the  opposite  side ;  inferiorly,  a  line  extending  from  the 
apex  of  the  mastoid  process  to  the  occipital  protuberance. 

CONSTITUENT   PARTS. 

i.  TJieSkin. 

Upon  the  mastoid  process,  this  membrane  is  thin,  smooth, 
shining,  destitute  of  hairs,  and  participates  in  all  the  characters 
of  that  which  covers  the  auricle ;  as  it  ascends,  it  becomes  con- 
siderably thicker  and  very  dense.  At  the  summit  of  the  region, 
the  hairs  pierce  it  almost  perpendicularly ;  as  they  descend,  more 
and  more  obliquely,  and  persist  for  a  greater  length  of  time  in 
this  than  in  the  other  regions. 

n.  The  Cellv to-adipose  Layer. 

Behind  the  ear,  it  is  altogether  cellular  ;  throughout  the  rest  of 
its  extent  we  meet  with  minute  adipose  vesicles,  which  are  enclos- 
ed in  very  compact  fibro-cellular  loculi,  as  in  the  frontal  and  pari- 
etal regions.  Upon  the  occipital  bone  this  layer  is  intimately 
adherent  to  the  skin,  for  which  reason  wounds  occurring  here 
with  loss  of  substance  cannot  be  approximated  ;  neither  by  sut- 
ures, which  would  be  dangerous,  nor  by  bandages,  which  would 
be  ineffectual.  Upon  the  os  temporis,  as  the  adherence  is  slight, 
wounds  may  be  immediately  united.  This  layer  encloses  all  the 
principal  vessels  and  nerves ;  its  union  with  the  subjacent  layer 
is  not  less  intimate  than  with  the  skin  ;  it  is  this  compact  union 
which  renders  the  dissection  of  the  occipito  frontalis  muscle  and 
the  epicranial  aponeurosis  so  difficult ;  and  it  is  also  for  this  rea- 
son that  the  skin  which  extends  from  the  forehead  to  the  occiput, 
follows  all  the  movements  produced  by  the  contractions  of  this 
muscle. 

HI.  The  Aponeurosis  and  Muscles. 

The  former  is  very  strong ;  its  fibres  are  very  distinct  in  this 
region,  and  in  some  subjects  it  puts  on  a  shining  and  pearly  ap- 
pearance. The  latter  are  ; — the  posterior  auricular,  which  at- 


1C  OF   THE    HEAD. 

taches  the  auricle  to  the  mastoid  process ;  then  the  occipital, 
which  covers  only  the  two  external  thirds  of  the  bone,  so  that 
above  the  occipital  protuberance  the  aponeurosis  alone  is  situated 
between  the  pericranium  and  subcutaneous  layer.  These  parts 
are  separated  from  the  pericranium  by  a  dense,  but  not  very  com- 
pact, lamellated  cellular  tissue.  The  superior  extremities  of  the 
sterno-mastoid  and  splenius  capitis  muscles,  although  not  specially 
appertaining  to  this  region,  must  nevertheless  be  noticed,  because 
their  attachments  near  the  mastoid  process  and  insertion  into  its 
apex,  expose  them  to  injury  when  operations  are  performed  at 
this  part ;  as  for  example  in  perforating  the  cells  of  the  mastoid. 

iv.  The  Pericranium. 

It  presents  nothing  peculiar  here,  unless  it  is  that  it  adheres 
more  firmly  to  the  bones,  on  account  of  the  roughness  of  their 
surface. 

v.  The  Arteries. 

The  most  important  are  the  occipital  and  posterior  auricular. 
The  former  enters  this  region  as  it  passes  from  between  the  sple- 
nius and  trapezius  muscles,  and  then  goes  to  inosculate  with  the 
posterior  branch  of  the  temporal ;  it  is  enveloped  in  the  subcuta- 
neous layer,  and  is  very  difficult  to  secure  by  ligature.  The  sec- 
ond slides  along  the  mastoido-auricular  furrow,  enters  the  posterior 
auricular  muscle  and  the  deep  fibrous  tissue,  gets  above  the  mas- 
toid process  and  anastomoses  with  the  preceding.  It  follows, 
from  this  distribution  of  these  arteries,  that  wounds,  or  incisions 
made  in  the  internal  and  superior  third  of  this  region,  will  not  be 
attended  with  hemorrhage ;  the  same  applies  to  the  mastoidien 
eminence,  unless  the  division  is  made  very  near  to  the  ear. 

We  should  likewise  notice  the  small  branch  of  the  occipital 
artery,  which  passes  to  the  dura  mater  through  the  foramen  mas- 
toideum  posterius. 

vi.    The  Veins. 

There  is  at  least  one,  and  often  two,  for  each  artery ;  they  fol- 
low exactly  the  same  course,  and  empty  their  blood  into  the  jugu- 


OF    THE    HEAD.  17 

lars.  Besides  these,  we  find  numerous  emissary  veins  coming  out 
at  the  lambdoidal,  mastoido-parietal  and  mastoido-occipital  su- 
tures, and  especially  one  of  very  large  size,  which  comes  through 
the  mastoid  foramen.  This  last  frequently  communicates  with 
the  venous  canals  of  the  diploe,  and  always  with  the  lateral  si- 
nus :  on  this  account,  we  are  advised  to  apply  leeches,  cupping 
glasses,  etc.  over  it,  in  order  to  remove  congestion  of  the  meninges 
promptly. 

vii.  The  Lymphatics. 

The  superficial  pass  to  the  posterior  glands  of  the  ear ;  the 
deep-seated  under  the  sterno-mastoid  muscle. 

vni.   The  Nerves. 

These  are  numerous,  and  originate,  1st,  from  the  posterior 
auricular  branch  given  off  by  the  facial,  as  it  emerges  from  the 
stylo-mastoid  foramen  ;  this  nerve  generally  divides  in  like  man- 
ner with  the  artery  of  the  same  name  ;  2d,  from  the  sub-mastoid 
branch  of  the  cervical  plexus  ;  this  branch  ramifies  in  the  subcu- 
taneous tissue,  and  is  distributed  principally  to  the  skin  ;  it  anasto- 
moses with  the  anterior  auricular  of  the  same  plexus,  with  fila- 
ments from  the  internal  frontal  and  sub-occipital ;  3d,  we  find  some 
twigs  from  the  first  cervical  pair,  and  the  posterior  branch  of  the 
sub-occipital.  The  latter  accompany  the  vessels,  and  ramify  in 
the  occipital  muscle,  aponeurosis  and  pericranium,  and  inosculate 
with  the  preceding,  but  especially  with  the  frontal.  From  this 
abundant  supply  of  nerves,  and  the  density  of  the  cellular  tissue 
in  which  they  creep,  we  may  explain  the  symptoms  which  ac- 
company inflammations  of  this  part  of  the  head,  and  those  which 
follow  operations  performed  upon  it.  Their  anastomoses  will 
also  teach  us  why  neuralgia  of  a  certain  point  of  the  cranium  is 
not  always  removed  by  the  section  of  the  principal  nerve  distrib- 
uted to  it ;  and  they  further  account  for  the  rapidity  with  which 
pain  and  inflammation  spread  from  the  occipital  region  to  all  the 
other  parts  of  the  head  and  neck.  It  may  be  well  to  note,  how- 
ever, that  the  return  of  pain,  after  a  nervous  branch  has  been  di- 


S  Oi     THE    HEAD. 

vided,  may  be  owing  to  the  possible  re-union  of  its  divided  ex- 
tremities, as  well  as  to  anastamosis. 

-  The  ganglionic  system  does  not  furnish  any  distinct  branch 
lo  this  region  ;  all  the  filaments  which  come  from  it  are  imbed- 
dot!  in  the  arterial  tunics. 

ix.  The  Skeleton. 

It  consists  of  the  mastoid  portion  of  the  temporal  bone,  the  in- 
terior angle  of  the  parietal,  a  portion  of  the  occipital,  and  the  su- 
tures which  unite  these  osseous  pieces. 

Each  of  these  portions  of  bone  present  certain  peculiarities 
worthy  of  notice.  Thus  the  ossa  wormiens,  which  frequently 
occur  in  the  lambdoidal  suture,  may  be  mistaken  for  fractures ; 
as  also  the  anormal  suture  which  separates  into  two  the  epactal 
undproral  portions  of  the  os  occipitis,  upon  the  median  line.  The 
existence  of  this  separation  in  the  adult  likewise  renders  the 
longitudinal  sinus  more  liable  to  rupture. 

The  portion  of  the  os  occipitis  appertaining  to  this  region, 
corresponds  to  the  posterior  lobe  of  the  cerebrum.  If  it  is  true, 
therefore,  as  M.  Gall  supposes,  that  the  organ  of  maternal  love 
resides  in  this  portion  of  the  brain,  we  will  readily  conceive  why 
this  part  of  the  cranium  is  more  prominent  in  the  female  than  the 
male,  and  why  wounds  or  fractures  here  have  sometimes  been  fol- 
lowed by  a  decided  change  in  this  faculty.  Further,  the  application 
of  the  trephine  should  always  be  made  in  preference  upon  the 
middle  of  the  lateral  prominence  of  the  occiput,  because  there  the 
bone  is  very  thin,  whereas  in  the  surrounding  parts  it  is  much 
thicker.  The  presence  of  the  occipito-parietal  suture  externally, 
of  the  longitudinal  sinus  internally,  and  of  the  lateral  sinus  infe- 
riorly,  opposite  to  the  superior  curved  line,  is  an  additional  reason 
in  favour  of  this  precept.  Neither  should  we  trephine  upon  the 
posterior  and  inferior  angle  of  the  parietal  bone,  because  it  cor- 
responds to  the  place  where  the  lateral  sinus  turns  behind  the 
petrous  portion  of  the  os  temporis.  It  is  at  the  junction  of  this 
angle  with  the  other  bones  that  we  find  a  fontanelle  in  the  fetus, 
which  may  remain  during  childhood.  Herniae  of  the  cerebellum 
have  protruded  at  this  part,  and  we  can  conceive  the  possibility 
of  them  :  those  of  the  cerebrum  may  also  occur  here. 

The  mastoidien  portion  of  the  temporal  bone  likewise  deserves 


OP    THE    HEAD.  10 

very  particular  attention.  In  the  first  place,  we  should  distinguish 
from  the  mastoid  process,  properly  so  called,  the  posterior  and 
superior  part  of  the  bone,  which  is  thin,  and  corresponds  to  the 
lateral  gutter.  This  mammoid  eminence  is  subject  to  numerous 
varieties,  with  which  it  is  useful  to  be  acquainted.  It  is  much 
less  prominent  in  the  infant  than  the  adult,  in  the  female  than  the 
male,  and  more  so  in  old  men ;  its  developement  almost  always 
depends  upon  the  cells  which  it  encloses,  and  through  which  it 
communicates  with  the  cavity  of  the  tympanum  ;  for  which  reason 
the  mastoid  process  has  been  perforated  in  order  to  give  exit  to 
pus,  or  other  fluids  extravasated  in  this  cavity,  as  well  as  to  admit 
of  the  entrance  of  air  into  it.  We  must  recollect,  however,  that 
this  operation  is  not  admissible  in  children,  in  whom  the  mastoid 
cells  are  not  developed ;  that  sometimes  the  paries  of  the  mastoid 
cavity  is  very  thick,  and  formed  of  two  compact  laminae  with  an 
intermediate  diploe,  which  would  prevent  our  arriving  at  the  cells 
readily ;  that,  in  other  cases,  this  wall  is  as  hard  as  ivory ;  and 
finally,  that  instances  have  occurred  in  which  the  cells  were  small, 
compact  and  having  no  communication  with  the  ear.  In  cases 
where  the  mastoid  cells  are  very  large  and  their  parietes  thin,  we 
should  not  forget  that  they  may  be  fractured  independent  of  the 
cranial  table. 

In  fine,  it  is  evident  that  the  mastoidien  portion  of  the  occipital 
region  deserves  the  greatest  attention,  on  account  of  the  numerous 
diseases  to  which  it  is  subject.  Indeed,  nature  herself  sometimes 
accomplishes  the  perforation  of  the  bone  in  order  to  give  issue  to 
pus  accumulated  within  the  ear,  and  caries  and  necrosis  of  this 
process  is  no  unfrequent  occurrence.  The  structure  and  arrange- 
ment of  the  tissues  render  inflammations  in  this  situation  danger- 
ous. This  region  is  sometimes  the  seat  of  tumours  arising  either 
from  tumefaction  of  the  lymphatic  glands  which  appertain  to  it, 
or  morbid  changes  of  some  other  nature  ;  finally  it  is  at  this  point 
we  apply  leeches,  cupping  glasses,  the  moxa  blisters,  etc.,  for  a 
great  variety  of  diseases. 

In  proceeding  from  the  surface  towards  the  bones  we  find  the 
parts  in  the  following  order  of  superposition :  1st.  the  skin ;  2d. 
the  cellulo-adipose  layer,  enclosing  the  nerves  and  principal  ves- 
sels ;  3d.  the  epicranial  aponeurosis  and  muscles ;  4th.  the  peri- 
cranium ;  5th.  the  skeleton. 


20  Of    THE    JlEAJi 

Sect.  4.  The  Cranium  in  General. 

There  are  some  remarks  applicable  to  all  the  regions  before 
treated  of,  into  the  detail  of  which  we  must  now  enter. 

1st.  The  density  of  the  skin,  the  hairs  and  the  numerous  follicles 
which  surround  their  roots,  appear  to  be  the  principal  reasons  for 
the  peculiar  character  which  the  different  species  of  Tinese  as- 
sume. 

2d.  It  is  on  account  of  the  slight  extensibility  of  the  skin  that 
tumours  developed  between  the  aponeurosis  and  integuments  are 
always  more  or  less  flattened  in  their  commencement. 

3d.  From  the  great  thickness  of  the  skin,  and  its  intimate 
adhesion  to  the  subjacent  tissues,  it  follows  that,  after  contusions, 
when  the  extravasated  matters  become  fluid,  we  feel  a  depression 
in  the  centre  of  the  swelling.  This  depression  is  sometimes  so 
striking  that  it  has  deceived  skilful  surgeons,  who  have  mistaken 
it  for  a  disease  of  the  bone,  and  even  for  a  fracture.* 

4th.  The  compact  texture  of  all  the  parts  covering  the  bones 
of  the  cranium  sufficiently  explains  why  its  inflammations  almost 
always  assume  the  erysipelatous  form;  why  its  ulcers  are  of 
difficult  cure ;  why  wounds  of  the  scalp,  with  the  least  loss  of 
substance,  are  seldom  susceptible  of  immediate  reunion ;  and  final- 
ly, when  these  wounds  suppurate,  why  the  pericranium  becomes 
detached,  and  permits  the  matter  to  penetrate  between  it  and  the 
bones,  thus  giving  rise  to  necrosis,  etc. 

5th.  The  tenuity  of  the  bones  in  a  great  number  of  places,  and 
the  frequent  vascular  communications  between  the  external  and 
internal  parts  of  the  cranium,  account  for  the  severity  of  most  of 
their  external  diseases,  by  the  facility  with  which  they  are  trans- 
mitted to  the  interior. 

6th.  There  are  a  great  number  of  points  upon  the  cranium 
where  surgeons  are  forbidden  to  apply  the  trephine,  many  of 
which  have  been  already  noticed  ;  but  it  remains  to  speak  of  the 
sutures  in  general. 

We  do  not  trephine  over  their  track;  1st.  because  it  is  diffi- 
cult to  separate  the  soft  parts  from  them  ;  2d.  because  they  ad- 
here firmly  to  the  dura  mater ;  3d.  because  they  generally  trans- 

*  See  J.  L.  Petit. 


OF   THE    HEAD.  21 

mit  emissary  veins  of  considerable  volume ;  4th.  because  their 
serrae  are  unequal  and  converted  into  ossa  wormiens ;  5th.  be- 
cause the  most  remarkable  of  them  correspond  to  large  sinuses. 
But  the  experience  of  Garengeot,  Sharp,  Marchettis,  Warner, 
Pott,  &c.  shews  us  that  this  last  motive  should  not  deter  us  when 
the  indications  are  positive. 

It  is  evident  that  the  most  of  these  anatomical  particulars  must 
render  this  operation  very  rare,  if  we  expect  to  derive  benefit 
from  it  by  trephining  over  these  points.  However,  in  conse- 
quence of  the  adhesion  of  the  dura  mater  to  the  sutures  it  is  diffi- 
cult for  fluids  to  become  extravasated  beneath  them  ;  but  if  this 
extravasation  has  already  taken  place,  the  dura  mater  is  then  de- 
tached, and  then  it  occasions  no  particular  impediment.  It  is  only 
in  those  cases  where  the  extravasation  exists  between  the  meninges 
that  this  separation  is  not  effected,  but  under  such  circumstances 
it  is  never  indispensible  to  trephine  over  the  sutures. 

7th.  Although  the  osseous  box  of  the  cranium  encloses  the  most 
delicate  organ  of  the  economy,  it  has  been  destroyed  in  a  great 
number  of  points,  either  by  repeated  trepanations*  or  by  dis- 
eases,! without  death  being  the  necessary  consequence. 

8th.  The  fontanelles  must  also  be  noticed.  Those  which  are 
seen  at  the  inferior  part  of  the  temporo-parietal  regions,  generally 
disappear  early  in  the  foetus :  they  afford  no  assistance  during 
parturition  ;  but,  as  we  have  already  stated,  hernia  cerebri  may 
protrude  through  these  membranous  spaces.  Criminals  have 
sometimes  introduced  needles,  and  other  instruments,  through 
these  spaces,  into  the  skulls  of  young  children,  in  order  to  destroy 
them. 

The  anterior  is  the  largest,  and  most  constant ;  it  is  rhomboi- 
dal,  and  the  four  sutures  which  run  into  it  cross  each  other  at  right 
angles,  which  distinguishes  it  from  the  occipital  fontanelle,  of 
which  we  shall  speak  presently.  The  frontal  fontanelle  being 
better  known  than  the  others,  it  has  been  supposed  that  pins,  and 
other  slender  foreign  bodies,  found  by  some  surgeons  within  the 
cranial  cavity,  without  any  trace  of  external  aperture,  have  been 
introduced  into  it  at  this  part.J  It  has  been  found  open  in  a 

*  Quesnoy,  Petit,     f  Lachariere,  Prof.  Richerand,  M.  Paillard. 
I  Valentin,  Voyage  en  Italic,  etc.,  Manne,  Bulletin  de  la  Soc'ieM  medicale  d> Emula- 
tion, Mai  1810. 


OF    THli    IIEAJ). 

young  man  of  twenty,*  and  in  another  of  thirty  years  oi 
age.f  The  continuance  of  this  deficiency  exposes  the  subject 
of  it  to  encephalocele,  and  it  is  for  the  purpose  of  preventing  such 
an  occurrence,  as  well  as  injury  from  external  agents,  that  quilted 
caps  of  various  constructions  have  been  recommended. 

The  posterior  fontanelle  is  frequently  closed  at  birth,  notwith- 
standing it  is  of  greater  importance,  as  it  regards  paturition,  than 
the  preceding,  since  it  is  uniformly  found  in  the  centre  of  the  part 
which  generally  presents :  we  distinguish  it  by  its  being  of 
smaller  size,  its  triangular  form,  and  especially  by  the  three 
branches  of  sutures  which  converge  towards  it.  The  direction 
of  these  lines  is,  in  fact,  the  sole  index  upon  which  we  can  de- 
pend in  order  to  ascertain  when  the  angle  of  the  occipital  bone  is 
not  ossified,  or  when  the  sagittal  suture  is  prolonged  towards  the 
foramen  magnum,  dividing  this  bone  into  two  symmetrical  por- 
tions. 

9th.  From  the  manner  in  which  the  different  bones  of  the  cra- 
nium are  arranged,  an  ovate  or  spheroidal  box  is  formed,  which 
resists  external  violence  after  the  manner  of  arches,  according  to 
Bertin,  and  of  spheres,  according  to  Beclard. 

ART.  II. OF   THE    FACE. 

We  may  divide  this  part  of  the  head  into  parotideal,  nasal,  or- 
bital, zygomato-maxillary,  masseterine,  genian,  mental,  labial, 
olfactive,  buccal  and  pharyngeal  regions. 

Sect.  1. — Parotideal  Region. 

As  this  region  does  not  appertain,  properly  speaking,  either  to 
the  cranium  or  neck,  we  have  preferred  connecting  it  with  the 
face. 

Its  form  is  pyramidal,  the  base  of  the  pyramid  corresponding 
with  the  skin,  its  apex  to  the  pharynx.  It  is  bounded,  superiorly, 
by  the  temporal  region  ;  posteriorly,  by  the  anterior  margin  of  the 
sterno-mastoid  muscle  ;  anteriorly,  by  the  posterior  border  of  the 
inferior  maxillary  bone,  and  inferiorly  by  a  line  drawn  from  the 
angle  of  the  jaw  across  the  sterno-mastoid  muscle. 

fc  Baubin.        t  Bartholinc. 


OP    THE    HEAD.  23 

Its  surface  presents  a  gutter  which  is  deeper  in  the  aged,  in 
men,  adults,  and  those  of  a  spare  habit,  than  in  children,  women 
and  those  who  are  corpulent.  This  gutter  is  continued  down- 
wards into  the  supra-hyoideal  region ;  upwards,  to  the  lobe  of 
the  ear ;  afterwards,  in  passing  between  the  auricle  and  mastoid 
process,  it  forms  only  a  simple  furrow  which  was  spoken  of  when 
on  the  occipital  region :  this  is  the  mastoido-auricular  furrow. 

We  feel,  in  the  parotideal  region,  quite  near  the  anterior  aspect 
of  the  tragus,  a  small  prominence  which  is  carried  forwards  when 
we  depress  the  jaw  ;  this  is  the  maxillary  condyle.  When  the 
mouth  is  shut,  there  exists  between  this  prominence  and  the  mas- 
seter,  in  emaciated  persons  who  have  not  a  very  large  parotid,  a 
slight  excavation.  This  depression  corresponds  to  the  posterior 
part  of  the  sigmoid  notch  of  the  jaw,  and  at  this  part  we  might 
easily  introduce  a  pointed  instrument  into  the  zygomatic  fossa. 
From  this  superficial  situation  of  the  condyle,  its  fractures  may  be 
easily  detected,  by  pressing  the  finger  upon  it,  and  at  the  same 
time  depressing  the  jaw. 

CONSTITUENT    PARTS. 

i.  The  Skin. 

This  membrane  is  delicate,  supple,  and  destitute  of  hairs  ;  it 
contains  numerous  sebaceous  follicles,  and  may  be  easily  raised  by 
tumours  forming  beneath  it,  without  yielding  however  to  any 
very  considerable  distension. 

ii.  The  Subcutaneous  Layer. 

It  is  composed  of  a  few  fibres  of  the  platysma,  and  a  pretty 
dense  cellular  layer,  the  characters  of  which  will  be  more  partic- 
ularly investigated,  when  we  speak  of  the  masseterine  region. 
In  the  superior  part  of  this  region  we  have  in  the  first  place  the 
ear,  which  requires  a  distinct  examination.  This  delicate  organ 
is  susceptible  of  surgical  considerations  in  its  external  and  middle 
portions  only,  we  will  therefore  speak  but  little  of  the  internal 
ear. 


•21 


OF   THE    HEAD. 


HI.  The  External  Ear. 


It  is  divided  into  the  Auricle  and  Meatus  Auditor-ins  Extemus, 
The  Auricle  commences  at  the  concha,  is  of  an  oval  form, 
its  largest  extremity  being  placed  upwards,  and  so  situated  that  its 
superior  half  rests  upon  the  temporal  region,  that  its  posterior  part 
conceals  the  mastoid  process,  and  that  its  anterior  and  inferior 
portion  alone  is  placed  in  the  parotideal  region.  It  is  composed. 
1st,  of  a  very  delicate  and  thin  skin,  which  slides  easily  over  the 
subjacent  tissues  ;  this  skin  is  smooth  throughout,  excepting  within 
the  tragus  and  antitragus,  where  a  few  hairs  are  generally  observ- 
ed ;  it  encloses  numerous  follicles,  in  which  the  sebaceous  matter 
sometimes  accumulates  and  concretes,  forming  small  encysted 
tumours  (loupes)  known  by  the  name  of  tannes  (acne  punctata). 
Where  the  auricle  attaches  itself  to  the  temple  by  means  of  the 
helix,  and  upon  the  face  by  means  of  the  lobe,  it  forms  two  dis- 
tinct folds.  3d.  Of  a  cellulo-fibrous  layer,  very  dense,  but  lam- 
ellated,  separated  from  the  cutaneous  envelope  by  a  more  supple 
cellular  tissue,  in  which  adipose  vesicles  are  never  met  with. 
When  small  purulent  abscesses  form  in  this  last  layer,  they  excite 
but  little  pain,  but  sometimes  burrow  with  great  rapidity  under 
the  skin,  giving  rise  to  intractable  sinuous  ulcers.  When,  on  the 
contrary,  these  abscesses  are  developed  in  the  former  tissue,  they 
occasion  very  acute  pain  and  sometimes  very  formidable  symp- 
toms :  3d,  of  the  five  small  muscles  of  the  auricle  ;  viz. :  the  he- 
licis  major  and  minor,  the  tragicus,  antitragicus,  and  transversus 
auriculae  :  4th,  of  arteries,  which  are,  the  posterior  auricular,  de- 
rived from  the  external  carotid,  and  the  anterior  auriculares,  from 
the  superficial  temporal :  5th,  of  veins  which  accompany  the  ar- 
teries :  6th,  of  lymphatic  vessels  which  are  rather  supposed  to 
exist  in  it ;  their  injection  being  rendered  so  difficult  by  the  close- 
ness of  the  cellular  tissue  in  which  they  are  enveloped,  that  they 
have  not  as  yet  been  discovered  but  by  very  few  anatomists. 
These  lymphatics,  according  to  Mascagni  and  Cruikshank,  pass 
to  the  parotideal  absorbent  glands,  and  the  tumefaction  which 
these  glands  undergo  in  consequence  of  certain  diseases  of  the 
external  ear,  seems  to  support  this  opinion :  7th,  of  numerous 
nerves,  which  are,  in  the  first  place,  anteriorly,  the  superficial 
temporal,  originating  from  the  inferior  maxillary ;  the  auricular 


OF    THE    HEAD. 

branch  of  the  cervical  plexus  ;  next,  posteriorly,  the  mastoid 
branch  from  the  facial,  which  we  have  already  seen  in  the  occi- 
pital region,  and  lastly,  the  sub-mastoid  branch  from  the  cervical 
plexus.  This  ample  supply  of  nerves  accounts  for  the  acute  sen- 
sibility of  the  external  ear,  and  the  symptoms  which  its  inflamma- 
tions usually  excite  in  it :  8th,  of  a  cartilage,  which  is  enveloped 
in  a  very  dense  species  of  perichondrium,  so  much  so  that  Bichat 
has  classed  this  substance  among  the  fibro-cartilages.  It  consti- 
tutes the  solid  parts  of  the  auricle,  and  determines  its  form,  emi- 
nences, depressions,  etc.  It  is  very  flexible,  which  defends  it 
from  being  fractured,  unless  it  has  become  ossified  by  age,  which 
is  a  very  rare  occurrence. 

Although  the  lobe  contains  almost  all  the  elements  which  have 
just  been  passed  in  review,  yet  these  diverse  tissues  present  certain 
differences  worthy  of  notice.  Thus,  the  skin  is  equally  delicate, 
but  more  freely  supplied  with  venous  capillaries  ;  hence  the  livid 
colour  it  assumes  on  exposure  to  cold,  or  when  respiration  and 
circulation  are  impeded.  Its  cellular  tissue  contains  very  small 
adipose  vesicles,  and  these  different  parts  are  so  much  confounded 
with  the  vessels,  nerves,  and  skin,  that  the  lobe  seems  to  form  a 
homogeneous  mass,  rather  than  a  complex  organ.  As  this  part  of 
the  auricle  possesses  but  little  sensible  tissue,  its  perforation  is 
scarcely  painful. 

The  meatus  auditorius  externus  is  about  an  inch  in  length,  and 
its  direction  obliquely  inwards,  downwards  and  forwards  ;  when 
cut  across,  its  figure  is  elliptical,  its  perpendicular  diameter  being 
greater  than  its  antero-posterior.  It  is  so  situated,  that  it  touches 
the  maxillary  condyle  anteriorly,  whereby,  when  the  jaw  is  de- 
pressed, this  canal  is  dilated.  It  is  for  this  reason,  says  M.  Riche- 
rand,  that  we  instinctively  open  the  mouth  the  better  to  distinguish 
sounds  which  we  are  anxious  to  hear.  Posteriorly,  it  lies  upon 
the  mastoid  process,  and  superiorly,  it  is  circumscribed  by  the 
superior  branch  of  the  horizontal  root  of  the  zygomatic  process. 

From  what  has  just  been  said,  it  follows  that  in  the  two  last 
directions,  the  meatus  auditorius  externus  is  securely  protected  by 
the  bones ;  whilst  inferiorly,  it  is  almost  uncovered.  The  dispo- 
sition of  this  canal  is  such,  that  forwards  and  downwards  its  par- 
ietes  are  concave,  and  two  lines  longer  than  upwards  and  back- 
wards, where  they  are  convex.  This  difference  in  length  is 

4 


(  OF    THE    I1EAJX 

produced  by  the  membrana  tympani,  which  is  inclined  obliquely 
inwards  and  forwards.  From  these  data,  the  principle  of  passing 
instruments  along  the  inferior  paries  of  the  canal,  when  we  wish 
to  extract  foreign  bodies  from  the  ear,  is  derived.  This  canal  is 
hollowed  out  in  the  os  temporis,  where  it  receives  a  prolongation 
of  the  auricle  ;  but  the  elements  of  this  auricle  here  present  some 
peculiarities  which  should  be  mentioned.  In  the  first  place,  the 
skin  gradually  loses  its  characters,  so  that  as  it  approximates  the 
membrana  tympani,  the  epidermis  alone  remains,  which  termi- 
nates in  a  cul-de-sac  upon  this  membrane  ;  next  the  follicles  are 
numerous,  and  secrete  the  cerumen,  which  sometimes  accumulates 
and  hardens,  producing  deafness,  especially  in  the  aged  ;  and 
finally  a  considerable  number  of  hairs  are  implanted  into  it,  which 
seem  destined  to  catch  minute  particles  of  dust,  etc.,  propelled  by 
the  air  towards  the  tympanum. 

The  cartilage  of  the  meatus  is,  as  it  were,  incised  from 
space  to  space  by  what  are  called  the  incisures  of  Santorini, 
and  these  fissures  permit  purulent  matter,  formed  in  the  vicinity, 
to  make  its  way  into  the  auditory  canal.  One  of  these  fissures 
is  met  with  in  the  superior  and  posterior  part,  quite  near  the 
anti-tragus;  another,  which  is  more  distinct,  upwards  and  for- 
wards, between  the  helix  and  tragus.  The  fibrous  tissue,  which 
alone  fills  these  fissures,  may  be  destroyed  by  the  pus  of  su- 
perficial abscesses ;  and  hence  be  discharged  through  the  meatus. 
We  have  but  recently  met  with  a  case  of  this  kind :  on  the  22d 

of  March,  1825,  Mr.  G ,  who  had  laboured  under  a  pustular 

inflammation  of  the  intestines  during  twenty-five  days,  was 
attacked  with  parotitis,  and  six  days  afterwards,  the  matter  made 
its  way  into  the  ear  through  the  last  mentioned  fissure.  Besides 
the  arteries  already  mentioned  when  on  the  auricle,  the  meatus 
auditorius  receives  branches  from  the  stylo-mastoidea  (auricula- 
ris  j)osterior)  and  from  the  temporalis  profunda  posterior.  The 
veins  are  of  no  importance  in  a  surgical  point  of  view.  The 
same  may  be  said  of  the  nerves :  we  sometimes  find  here, 
however,  a  filament  from  the  great  sympathetic,  running  to 
anastomose  with  the  facial. 

iv.  T/te  Middle  Ear  or  Tympanum 
The  cavity  of  the  tympanum  may  be  considered  as  a  dilata- 


OF   THE    HEAD. 

lion  of  the  preceding  canal,  from  which  it  is  separated  only  by 
a  thin  and  fragile  membrane.  Below  this  box  we  find  the 
glenoid  cavity :  anteriorly  and  a  little  more  internally  it  corres- 
ponds to  the  carotic  canal ;  which  may,  in  some  measure,  ac- 
count for  the  buzzing  in  the  ears  which  patients  with  aneurism 
of  the  internal  carotid  sometimes  experience.  From  its  relations 
with  the  fissure  of  Glaser,  blood,  pus,  &c.,  may  penetrate  from 
the  cavity  of  the  tympanum  into  the  ternporo-maxillary  articu- 
lation. 

The  mastoid  process  and  cells  are  situated  posterior  and 
external  to  the  tympanum,  and  as  the  cells  are  separated  from 
this  cavity  only  by  the  mucous  membrane  of  the  latter,  we 
conceive  that  abscesses  of  the  ear  may  be  evacuated  through  a 
perforation  made  in  this  process.  The  superior  wall  of  the 
middle  ear  is  thin,  and  corresponds  to  the  anterior  aspect  of 
the  petrous  portion  of  the  os  temporis.  Vascular  porosities  are 
observed  in  it,  which  form  a  communication  between  the  dura 
mater  and  the  mucous  membrane  of  the  tympanum.  We  also 
see  here,  in  the  child,  and  sometimes  in  the  adult,  a  trace  of 
suture  which  transmits  cellulous  processes  and  emissary  veins : 
this  disposition  accounts  for  inflammation  of  the  meninges  arising 
from  acute  otitis,  discharges  of  blood  from  the  ears  after  blows 
or  falls  upon  the  head,  and  tinnitus  aurium  in  diseases  of  the 
brain,  &c. 

The  external  paries  of  the  cavity  is  formed  by  the  membrana 
tympani,  a  species  of  horny  lamina,  covered  externally  by  the 
cuticle  of  the  meatus  and,  internally,  by  the  mucous  lining  of  the 
tympanum.  According  to  Rivinus,  Scarpa,  Witteman,  Vest, 
&c.,  it  is  naturally  perforated;  but  this  perforation  is  probably 
only  an  anomaly  or  an  accidental  occurrence.  Be  this  as  it 
may,  when  this  state  exists,  we  can  readily  comprehend  how 
gaseous  or  other  fluids,  such  as  tobacco-smoke,  air,  blood,  &c. 
may  be  propelled  from  the  mouth  through  the  ear.  In  general 
this  does  not  impair  the  hearing,  unless  accompanied  with  a  disea- 
sed state  of  this  organ.  The  manubrium  of  the  malleus  is  fixed 
between  the  laminae  of  the  membrana  tympani,  a  little  below 
and  before  its  centre  ;  and  it  is  for  this  reason  that  the  operation 
recently  advised  by  Portal,  Cooper,  &c.,  for  the  cure  of  certain 
forms  of  deafness  should  be  performed  low  down  and  upon  the 


j  OF   THE    HEAD. 

anterior  half  of  this  membrane.  This  remark  is  equally  applica- 
ble to  any  other  perforations  of  the  membrana  tympani  which 
diseases  of  the  ear  may  require.  We  should  always  be  careful, 
in  performing  these  operations,  not  to  introduce  the  instrument 
too  far,  lest  we  wound  the  chorda  tympani,  which  comes  from 
the  posterior  paries  of  the  cavity  in  order  to  pass  out  at  the 
glenoid  fissure.  The  opening  of  the  Eustachian  tube  is  at  the 
inner  and  fore  part  of  this  cavity.  This  canal,  which  is  of  great 
importance  in  surgical  practice,  on  account  of  the  frequency  of 
its  diseases  and  the  operations  which  they  require,  runs  obliquely 
forwards  and  inwards,  between  the  petrous  and  squamous  por- 
tions of  the  temporal  bone,  towards  the  top  of  the  pharynx, 
where  it  terminates  behind  the  opening  of  the  nasal  fossa?.  Its 
dimensions  generally  increase  as  it  passes  from  the  tympanum 
towards  the  pharynx,  which  renders  easy  the  introduction  of  a 
probe  from  the  nostrils ;  but  we  will  have  occasion  to  speak  of 
this  again. 

The  internal  membrane  of  the  middle  ear  is  a  prolongation  of 
that  of  the  pharynx ;  it  is  thin,  but  very  distinct  in  some  persons, 
especially  towards  the  mastoid  cells.  It  envelopes  the  whole 
chain  of  bones,  but  does  not  penetrate  into  the  labyrinth,  on 
account  of  the  horny  plates  which  close  the  fenestrae  rotunda  et 
ovalis  ;  and  its  nature  renders  it  susceptible  to  the  same  diseases 
with  the  mucous  membrane  of  the  pharynx.  The  cellular  tissue 
which  connects  it  to  the  bones  is  very  compact ;  we  may  con- 
sider it  as  a  species  of  internal  periosteum,  and  from  its  density 
we  may  comprehend  why  inflammations  of  the  ear  are  so  pain- 
ful. The  membrane  which  lines  the  cavity  of  the  tympanum 
receives  its  arteries  from  the  stylo-mastoidea.  The  internal  car- 
otid gives  off  some  twigs  to  the  soft  parts  of  this  cavity  which 
pass  through  a  small  distinct  foramen ;  finally,  it  receives  some 
from  the  meningea  media,  by  the  canal  which  lodges  the  tensor 
tympani,  and  from  the  maxillaria  interna  by  the  fissure  of  Glaser. 

The  veins  follow  exactly  the  course  of  the  arteries,  and  afford 
no  interest  here.  We  have  already  mentioned  what  we  had  to 
say  respecting  them  when  treating  of  the  emissary  veins  of  the 
superior  paries  ;  like  all  other  emissary  veins  they  are  destitute 
of  valves,  and  empty  their  blood  into  the  dura-matral  sinuses. 

The  lymphatic  vessels  have  never  been  injected. 


OF   THE   HEAD.  29 

The  nerves  of  the  middle  ear  appertain  to  the  facial,  the 
carotic  plexus  and  the  spheno-palatine  ganglion;  from  which 
result  complicated  anastomoses,  which  may  explain  why  diseases 
of  the  internal  ear  excite  such  a  variety  of  sympathetic  affections. 
We  have  already  spoken  of  the  chorda  tympani  which  comes 
from  the  vidian  nerve.*  If  we  consider  that  this  chord,  in  cros- 
sing the  tympanum,  passes  above  the  malleus,  it  will  afford  us  an 
additional  reason  for  perforating  the  membrani  tympani  at  its 
inferior  part. 

The  internal  ear  having  no  relation  with  surgery,  we  do  not 
consider  it  our  duty  to  speak  of  it. 

V.  The  Parotid. 

Next  to  the  ear  we  find  the  gland  from  which  the  parotideal 
region  derive  its  name.  This  organ  covers,  anteriorly,  the  pos- 
terior margin  of  the  jaw,  and  is  prolonged  more  or  less  upon  its 
external  surface.  Between  this  bone  and  the  gland,  we  find,  from 
above  downwards,  the  superficial  temporal  artery  and  vein  ;  then 
the  facial  nerve,  which  crosses  the  vessels  opposite  the  neck  of 
the  condyle,  imbedded  in  the  deep  granules  of  the  gland  ;  next 
the  facial  or  transverse  facial  arteries ;  several  veins  of  consider- 
able volume,  which  ramify  in  the  secretory  tissue ;  finally  the 
cervico-facial  branch  of  the  respiratory  nerve  of  the  face,  (portio 
dura,)  the  termination  of  the  stylo-maxillary  ligament,  and  the 
masseter. 

Posteriorly,  the  parotid  gland  is  somewhat  firmly  fixed,  from 
above  downwards,  and  from  before  backwards, — first,  to  the 
auditory  canal,  then  to  the  fore  part  of  the  mastoid  process  and 
the  anterior  edge  of  the  sterno-mastoid  muscle ;  between  the  ear 
and  the  mammoid  process  it  covers  the  posterior  auricular  artery  ; 
upon  the  apex  of  this  apophysis,  and  externally,  it  lies  upon  an- 
other artery,  which  is  sometimes  larger  than  the  preceding. 

Internally  or  deeply,  it  rests  upon  the  trunk  of  the  facial  nerve 
and  the  three  filaments  which  are  detached  from  it  at  its  exit 
from  the  stylo-mastoid  foramen ;  then  upon  the  styloid  process 
and  the  musculo-fibrous  bundle  arising  from  it ;  upon  the  digas- 
tric muscle,  then,  a  little  farther  forwards,  upon  the  styloidien  ar- 

*  M.  H.  Cloquct. 


30 


OF  THE    HEAD. 


tery,  upon  many  anonymous  twigs  which  penetrate  the  glandular 
lobules,  and  are  lost  in  their  substance  ;  upon  the  trunk  even  of 
the  external  carotid,  behind  which  the  gland  sends  a  process 
which  sometimes  dips  very  deep,  and  is  applied  upon  the  glosso- 
pharyngeal  nerve,  the  internal  jugular,  and  internal  carotid.  It 
is  this  last  lobule  which  presented  so  many  difficulties  to  Prof. 
Beclard  when  he  extirpated  the  parotid  in  1823.  In  this  situa- 
tion, the  gland  and  the  arteries  are  so  intimately  connected,  that 
it  is  almost  impossible  to  remove  the  one  without  wounding  the 
others.  The  occipital  and  inferior  pharyngeal  arteries  are  like- 
wise covered  by  the  parotid,  which,  on  the  other  hand,  is  finally 
prolonged  between  the  pterygoid  muscles  and  the  styloid  process 
as  far  as  the  pharynx,  passing  between  the  external  carotid  and 
the  stylo-maxillary  ligament.  In  the  latter  direction,  this  gland 
is  continuous  with  the  submaxillary. 

These  are  the  complicated,  numerous,  and  important  relations, 
which  render  the  total  extirpation  of  the  parotid  so  dangerous 
and  almost  impossible ;  and  hence  we  are  induced  to  affirm,  that 
this  gland  was  never  completely  extirpated,  previous  to  the  ope- 
ration by  Beclard.* 

It  is  evident  that  this  operation  cannot  be  terminated  without 
applying  a  ligature  to  the  external  carotid  ;  the  facial  nerve  would 
necessarily  be  removed  ;  in  seeking  for  the  deep  prolongation  of 
the  gland,  there  would  be  the  greatest  danger  of  wounding  the 
internal  carotid  artery ;  so  with  the  internal  jugular,  the  occipital, 
superficial  temporal,  and  internal  maxillary  arteries.  It  is  possi- 
ble, however,  that  these  last  organs  might  be  avoided  if  the  parts 
remained  in  their  natural  relations.  But  what  disease  of  the  par- 
otid is  there,  sufficiently  severe  to  demand  its  extirpation,  which 
will  not  derange  the  relative  position  of  these  organs  ?  All  the 
lobules  of  the  gland  are  separately  enveloped  in  a  small  cellular 
sac  of  considerable  density ;  and  are  united  together  by  a  fila- 
mentous tissue  of  still  greater  density.  It  is  in  this  tissue  that 
critical  inflammations  of  the  parotid  appear  to  have  their  seat, 
whilst  the  mumps  affect  more  particularly  the  glandular  element. 
The  entire  gland  is  afterwards  enclosed  in  a  species  of  fibrous 
envelope,  the  external  and  firmest  lamina  of  which  is  derived 

"Archives  gtntrales  dc  Mtdccine.  Janvier,  1824.  Observation  de  M.  BeclarH. 
par  M.  Berard. 


OP   THE    HEAD.  31 

from  the  aponeurosis  which  covers  the  sterno-mastoid  and  tem- 
poral muscles,  and  is  continued  over  the  external  surface  of  the 
masseter.  The  internal  or  deep  lamina  also  comes  from  the 
same  parts ;  but  is  more  irregularly  distributed ;  it  furnishes 
sheaths  for  all  the  vessels,  envelopes  all  the  processes  which  this 
gland  sends  between  the  muscles,  and  unites,  anterior  to  it,  with 
the  external  aponeurotic  lamina.  Above  and  external  to  the  di- 
gastric muscle,  these  two  lamina  are  continuous  with  the  fascia 
cervicalis  and  the  stylo -maxillary  ligament.  Finally,  behind  the 
angle  of  the  jaw,  and  on  the  inner  side  of  the  pterygoideus  inter- 
nus  muscle,  they  pass  from  the  parotid  to  the  submaxillary  gland, 
to  which  they  equally  furnish  a  sheath. 

From  the  compact  structure  of  the  elements  which  unite  and 
envelope  the  parotideal  granulations,  we  may  account  for  the 
severity  of  their  acute  inflammations,  and  the  tendency  of  these 
inflammations  to  terminate  by  induration ;  also,  when  suppura- 
tion has  taken  place  in  them,  for  the  difficulty  with  which  the  pus 
accumulates  in  the  form  of  abscess ;  for  the  difficulty  of  detect- 
ing these  abscesses  when  situated  beneath  the  aponeurosis ;  and 
for  their  disposition,  in  certain  cases,  to  penetrate  towards  deep- 
seated  parts,  such  as  the  pharynx,  tongue,  etc.,  or  towards  the 
auditory  canal,  into  which  they  as  frequently  open,  rather  than 
towards  the  skin.  The  very  wise  precept,  of  making  an  early 
opening  into  tumours  of  the  parotideal  region,  in  which  we  sus- 
pect the  presence  of  pus,  is  founded  upon  these  considerations.* 
The  parotid  is  separated  from  the  skin  by  a  layer  of  cellular  tis- 
sue, generally  of  considerable  density,  including  some  fibres  of 
the  platysma,  nervous  filaments  of  the  facial,  an  ascending  branch 
of  the  cervical  plexus,  and  sometimes  venous  branches  which 
pass  to  the  external  jugular.  This  layer  seldom  contains  fat ;  it 
adheres  firmly  to  the  gland  and  integuments,  for  which  reason 
tumours  which  form  in  it  enlarge  with  difficulty,  and  generally 
possess  but  little  mobility. 

vi.  The  Muscles. 

They  are  of  but  little  importance  here,  in  relation  to  practical 
surgery.     In  addition  to  those  which  form  the  limits  of  the  re- 

*  Colles  Surgical  Anatomy,  page  132 


2  OF    THE    HEAD. 

gion,  we  find  posteriorly,  between  the  sterno-mastoid  and  the 
origin  of  the  digastric,  the  complexus  minor ;  upon  the  spine, 
the  rectus  capitis  lateralis,  rectus  capitis  anticus  major  and  minor ; 
internally,  the  stylo-hyoideus,  stylo-glossus,  and  stylo-pharyngeus, 
between  which  the  gland  sends,  as  we  have  said,  prolongations, 
so  that  they  are  liable  to  be  divided  during  the  extirpation  of  this 
organ ;  a  circumstance  which  would  not  fail  to  derange,  in  a 
serious  manner,  the  functions  of  the  larynx,  tongue,  and  pharynx. 
More  deeply,  the  constrictor  pharyngseus,  and  anteriorly  the 
pterygoid  muscles,  are  the  only  ones  which  we  here  observe.  A 
little  lower  down,  inwards  and  backwards,  we  see  the  stylo- 
maxillary  ligament,  which  we  should  avoid  in  operations,  on 
account  of  its  relations  with  the  stylo-glossus  muscle  and  its 
attachment  to  the  os  hyoides. 

vn.  The  Arteries. 

These  are  large  and  numerous.  We  find  here  the  trunks  of 
the  two  carotids,  and  the  greater  part  of  the  branches  given  oft" 
by  the  external ;  viz.  the  occipital,  pharyngeal,  stylo-mastoideal, 
the  commencement  of  the  external  maxillary  and  of  the  super- 
ficial temporal,  the  transverse  facial,  etc. 

1st.  The  External  Carotid  at  first  placed  very  deeply  within, 
on  a  level  with,  and  a  little  above,  the  digastric  and  stylo-hyoid 
muscles,  afterwards  ascends,  in  order  to  arrive  behind  the  con- 
dyle  of  the  jaw,  forming  an  arch  which  is  convex  externally.  In 
this  last  direction,  as  well  as  posteriorly,  it  is  enveloped  by  the 
gland,  to  which  it  firmly  adheres ;  anteriorly,  it  is  separated  from 
the  posterior  border  of  the  maxillary  bone  by  a  vein  of  consid- 
erable size  ;  the  cervico-facial  branch  of  the  seventh  pair  crosses 
it  obliquely  outwards,  in  its  course  to  the  face  and  neck. 

2d.  The  internal  maxillary  separates  from  the  carotid  on  a 
level  with  the  neck  of  the  condyle,  about  one  inch  and  three 
quarters  above  the  angle  of  the  jaw ;  posteriorly  and  internally, 
it  is  only  contiguous  to  the  parotid  gland ;  anteriorly,  it  makes  n 
sudden  turn  under  the  neck  of  the  maxillary  bone,  and  plunges 
between  the  pterygoid  muscles  ;  whence  it  follows  that,  in  frac- 
tures of  this  neck,  the  artery  may  be  ruptured  and  occasion  a 
troublesome  haemorrhage. 


OP    THE    HEAD.  33 

3d.  The  superficial  temporal,  in  ascending,  inclines  more  and 
more  outwardly,  as  far  as  the  anterior  part  of  the  meatus  audito- 
rius.  Anteriorly,  it  is  separated  from  the  condyle  only  by  its 
superficial  vein  and  by  dense  cellular  tissue  ;  posteriorly  and  ex- 
ternally, it  is  covered  first  by  the  parotid,  then  by  the  skin  and 
the  fore-part  of  the  auditory  canal.  It  lies  so  near  the  skin  that  it 
may  be  tied,  should  circumstances  require  it. 

4th.  The  occipital  lies  deep  in  the  lower  part  of  the  region  :  it 
is  at  first  situated  behind  and  internal  to  the  stylo-hyoid  muscle  ; 
then  it  passes  between  the  internal  jugular  vein,  which  it  crosses 
nearly  at  a  right  angle,  and  the  digastric,  in  order  to  arrive  at  the 
internal  surface  of  the  sterno-mastoid  muscle.  It  does  not  ad- 
here firmly  to  the  gland,  so  that  it  would  not  hinder  the  removal 
of  this  organ. 

5th.  The  stylo-mastoideal  ascends  almost  perpendicularly  to- 
wards the  foramen  of  the  same  name :  it  is  separated  from  the 
preceding,  which  is  internal  to  it,  by  the  stylo-hyoid  muscle,  and 
from  the  external  carotid,  which  is  before  it,  by  a  prolongation  of 
the  parotid  gland.  The  posterior  auricular  branch,  which  ori- 
ginates from  this  artery  about  an  inch  below  the  stylo-mastoid 
foramen,  is  obliged  to  pass  through  the  glandular  tissue,  in  order 
to  arrive  at  the  mastoido-auricular  furrow.  It  is  this  which  is 
most  exposed  to  the  action  of  the  instrument  when  we  endeavor 
to  divide  the  facial  nerve  at  its  exit  from  the  cranium. 

6th.  The  transverse  facial  arteries  adhere  so  firmly  to  the 
parotid  behind  the  masseter,  that  it  is  scarcely  possible  to  separate 
them  upon  the  living  subject,  when  performing  operations  at 
this  part. 

7th.  A  considerable  number  of  anonymous  arteries,  branches  of 
the  preceding,  are  also  scattered  throughout  the  gland,  consti- 
tuting its  vasa  propria  ;  but  none  of  them  are  so  regular  or  large 
as  to  merit  particular  notice. 

VIH.  The  Veins. 

In  general,  the  veins  accompany  the  arteries  and  possess  the 
same  relations  ;  but  there  is  also  an  additional  number  of  branches 
at  the  surface  and  in  the  substance  of  the  gland,  which  unite  to- 
gether externally,  in  order  to  form  the  external  jugular ;  besides, 

5 


OF    THE    JiEAD, 

we  find,  in  the  inferior  part  of  this  region,  the  anastomotic  branch 
of  the  two  large  veins  in  the  neck. 

The  internal  jugular  vein  lies  deep  upon  the  fore  part  of  the 
transverse  processes  of  the  first  three  cervical  vertebra?,  poste- 
rior and  internal  to  the  styloid  process  and  the  muscles  which 
arise  from  it,  to  the  parotid  gland  and  all  the  arteries,  with  the 
exception  of  the  internal  carotid,  which  is  upon  its  pharyngeal 
side.  It  is  crossed  in  this  place  by  the  ninth  (hypoglossal)  and 
spinal  accessory  nerves.  Its  relations  with  the  anterior  cerebral 
artery,  the  great  sympathetic  and  par  vagum,  are  similar  to  those 
which  we  will  find  in  the  neck. 

ix.   The  Nerves. 

In  the  subcutaneous  layer,  we  find  the  anterior  auricular  nerve 
of  the  cervical  plexus,  which  is  hard  and  its  branches  flattened. 
The  principal  branch  of  this  nerve  runs  along  the  external  jugu- 
lar vein. 

The  spinal  or  accessory  nerve  is  deeply  situated,  and  at  first 
runs  obliquely  between  the  internal  jugular  vein  and  the  digastric 
muscle  ;  it  then  traverses  the  posterior  and  inferior  lobules  of 
the  gland,  in  its  way  to  perforate  the  sterno-mastoid  muscle. 

Still  deeper  we  find  the  glossol-pharyngeal  and  hypoglossal 
(9th  pair)  nerves :  one  of  which  is  situated  within,  the  other 
without,  but  both  anterior  to  the  internal  jugular  vein  and  inter- 
nal carotid. 

The  pneumo-gastric  (par  vagum)  nerve  descends  behind  these 
two  vessels  and  gives  off  its  pharyngeal  branch  in  this  region. 

Still  nearer  the  bones,  is  the  superior  cervical  ganglion  of  the 
great  symphatetic,  and  the  filaments  which  go  to  form  the  caro- 
tid plexus. 

Finally,  the  important  nerve  of  this  region  is  the  facial  (portio 
dura.)  After  coming  through  the  stylo-mastoid  foramen,  previ- 
ously having  given  off  its  three  twigs,  this  trunk  descends  ob- 
liquely outwards  and  forwards  through  the  deep  lobules  of  the 
parotid,  before  the  mastoid  process.  It  is  at  this  point  we  must 
divide  it,  if  we  wish  to  suspend  its  action  or  remove  neuralgic 
symptoms.  This  may  be  done  without  difficulty  by  making  an 
incision  from  the  back  of  the  ear  to  the  lowest  part  of  this  pro- 


OP   THE    IIEA.O.  35 

cess,  from  which  we  must  separate  the  gland  by  drawing  the 
anterior  lip  of  the  wound  forcibly  forwards,  then  dissecting  cau- 
tiously, we  will  find  the  nerve  at  the  depth  of  about  six  lines,  in 
the  middle  of  the  space  which  separates  the  fibrous  canal  of  the 
ear  from  the  apex  of  the  mammoid  process.  As  the  posterior 
auricular  and  submastoideal  arteries  are  situated  directly  upon 
this  eminence,  we  will  readily  avoid  them  by  inclining  the  inci- 
sion a  little  further  forwards. 

It  is  in  passing  through  the  parotid  in  order  to  arrive  at  the 
external  part  of  the  superficial  carotid  that  the  portio-dura  di- 
vides into  two  branches :  the  temporo-facial  then  ascends  in  a 
direction  which,  if  continued,  would  reach  the  middle  of  the 
zygomatic  arch,  and  it  is  so  situated  in  this  track,  that  it  may  be 
easily  discovered  by  making  an  incision  three  or  four  lines  in 
front  of  the  ear.  We  would  have  to  divide  the  skin,  aponeu- 
rosis,  and  the  parotid  itself,  which  is  thin  at  this  part ;  the  nerve 
will  then  be  found  anterior  to  the  union  of  the  lobe  of  the  ear 
with  the  skin  of  the  face ;  that  is  to  say,  eight  lines  below  the 
horizontal  root  of  the  zygomatic  process,  upon  the  neck  of  the 
condyle  of  the  lower  jaw.  We  must  be  careful  to  cut  obliquely 
from  above  downwards,  and  from  before  backwards,  in  order 
to  avoid  the  temporal  artery ;  we  have  also  to  apprehend,  in 
endeavouring  to  make  a  section  of  this  nerve,  the  wounding  of 
the  transverse  facial  arteries.  It  would  not  be  difficult,  how- 
ever, to  compress  them  against  the  masseter.  We  may  remark 
that  after  the  section  of  this  nerve  its  action  is  not  necessarily 
destroyed,  since  the  cervico-facial  branch  remains.  On  this  ac- 
count, it  is  preferable  to  operate  anterior  to  the  mastoid  pro- 
cess, if  we  do  not  wish  to  see  the  pains  continue  or  re-appear, 
as  has  happened  in  two  patients  operated  upon  by  Prof.  Roux. 

We  will  examine  the  cervico-facial  branch  in  the  supra-hyoi- 
deal  region. 

x.     The  Lymphatics. 

These  vessels  are  numerous  in  the  parotideal  region,  and  their 
glands  deserve  particular  attention,  because  they  receive  almost 
all  the  lymphatics  from  the  exterior  of  the  cranium,  and  some  of 
those  of  the  face,  mouth  and  pharynx.  Some  of  these  glands 


30  UI     THE    HEAD. 

are  superficially  situated  upon  the  external  surface  of  the  paro- 
tid ;  others  more  deeply,  between  it  and  the  different  tissues  of 
this  region ;  we  generally  meet  with  two  or  three  before  or  be- 
low the  mastoid  process.  The  frequent  tumefaction  of  these 
bodies,  in  consequence  of  disease  of  the  skin,  of  the  cranium,  or 
or  of  the  sides  of  the  face,  has  often  led  to  the  necessity  of  re- 
moving them,  and  we  are  induced  to  believe  that  the  cases  of  ax- 
tirpation  of  the  parotid,  related  by  authors,  were  nothing  more. 

Finally,  there  are  some  glands  situated  between  the  sterno- 
mastoid  muscle  and  the  internal  jugular  vein,  which  form  the 
commencement  of  the  submastoideal  cervical  chain.  These  last 
receive  their  vessels  from  the  deep-seated  parts,  and  may,  when 
enlarged,  be  mistaken  for  aneurism,  compress  the  vessels,  and 
produce  serious  consequences. 

xi.  The  Skeleton. 

The  bones  of  this  region  are  only  met  with  superiorly,  posteri- 
orly, and  anteriorly. 

In  the  first  direction,  we  observe  the  inferior  surface  of  the 
petrous  portion  of  the  temporal,  the  glenoid  cavity  and  foramen 
caroticum;  then  the  occipito-petrous  suture,  in  the  posterior 
part  of  which  is  the  foramen  lacerum  posterius,  which  gives  pas- 
sage to  the  internal  jugular  vein,  the  spinal  accessory  nerve,  and 
par  vagum ;  then  the  basilary  process,  into  which  the  anterior 
recti  capitis  muscles  are  inserted ;  posteriorly  the  anterior  con- 
dyloid  hole  for  the  transmission  of  the  ninth  pair ;  the  stylo- 
mastoid  foramen  for  the  facial  nerve,  &c. 

In  the  second,  we  have  only  the  fore  part  of  the  transverse 
processes  of  the  three  first  cervical  vertebrae,  upon  which  lie  the 
anterior  branches  of  the  nerves  of  the  same  name. 

In  the  third  direction,  we  find  the  posterior  border  of  the 
lower  jaw  only ;  but  we  cannot  abandon  this  part  without  ma- 
king a  few  remarks  upon  the  temporo-maxillary  articulation. 

The  glenoid  cavity  being  bounded  posteriorly  by  the  styloid 
and  vaginal  processes,  and  the  vertebral  column,  does  not  admit 
of  luxations  of  the  condyle  in  this  direction.  Internally  the  spi- 
nous  process  of  the  sphenoid  bone  prevents  its  displacement  on 
this  side,  and  for  the  same  reason  opposes  the  luxation  outwards, 


OF   THE   HEAD.  37 

since  one  of  the  condyles  cannot  be  thrown  outwards  without 
the  other  being  driven  inwards ;  therefore,  it  is  forwards  only 
that  the  maxillary  bone  can  be  dislocated,  because  the  condyle, 
when  the  jaw  is  depressed,  always  tends  to  the  slide  upon  the 
transverse  root  of  the  zygomatic  process  (eminentia  articularis). 
Furthermore,  it  is  impossible  for  this  accident  to  occur  during 
infancy,  as  the  acute  angle  at  which  the  os  maxillare  inferius  and 
os  temporis  are  then  articulated  presents  an  insuperable  obsta- 
cle to  it. 

As  this  articulation  is  only  separated  from  the  skin,  externally, 
by  a  simple  ligament,  wounds  inflicted  upon  this  side  may  very 
readily  open  it. 

The  reddish  cellular  tissue,  which  fills  the  glenoid  cavity  pos- 
teriorly, forms  an  elastic  mass  of  greater  or  less  thickness,  which 
separates  the  cbndyle  from  the  auditory  canal,  but  permits  them 
to  approximate  very  much  when  the  jaw  is  greatly  depressed.  It 
is  this  tissue  which  shuts  in  part  the  fissure  of  Glaser,  and  prevents 
a  direct  communication  between  the  articulation  and  the  tympa- 
num. It  is  on  the  inner  side  of  this  chink,  and  without  the  cavity 
of  the  joint  that  \ve  find  the  corda  tympani ;  it  is  also  on  the  inner 
side  of  the  condyle  that  the  auricular  nerve  is  seen  coming  from 
the  inferior  maxillary,  and  passing  towards  the  temple  where  it 
forms  the  superficial  temporal ;  wThence  the  possible  alteration  of 
this  large  branch  in  diseases  of  the  articulation. 

Section  2.  Nasal  Region. 

It  is  bounded  superiorly  by  the  frontal ;  inferiorly  by  the  labial ; 
and  on  each  side  by  the  orbital  and  zygomato-maxillary  regions. 

CONSTITUENT    PARTS. 

i.  The  Skin. 

This  membrane  is  pretty  thick  between  the  eye-brows  and  up- 
on the  root  of  the  nose  ;  in  the  rest  of  the  region  it  is  thin,  and  of 
but  little  extensibility.  In  the  first  situation  it  is  sometimes 
covered  with  hairs  ;  upon  the  nose,  never.  It  contains  a  great 
number  of  sebaceous  follicles  ?  for  which  reason  this  part  of  the 


38  OF   THE    HEAD. 

face  is  speedily  covered  with  a  greasy  exudation.  The  secretion 
from  these  follicles  is  profuse,  especially  in  the  skin  of  the  lobule, 
and  in  the  lateral  furrow  of  the  nose,  and  in  certain  subjects  it  may 
be  squeezed  out  from  the  cryptae  in  the  form  of  small  filaments. 
When  this  animal  oil  becomes  still  more  concrete  it  remains  in 
the  follicles  and  frequently  forms  tannes  (acne  punctata)  which 
seldom  acquire  any  considerable  volume. 

ir.  The  Cellular  Layer. 

Upon  the  body  of  the  nose  it  is  thin,  dense,  corrpact  and  des- 
titute of  adipose  vesicles  ;  but  at  its  root  it  is  thicker,  more  lax, 
and  encloses  very  minute  adipose  cells.  It  is  on  account  of  its 
compact  texture,  in  the  first  instance,  that  tumours  occurring  in 
this  layer  are  small,  flattened  and  circumscribed,  that  abscesses 
rarely  form  in  it,  and  that  its  inflammations  generally  assume  the 
erysipelatous  character ;  whilst  at  its  root,  the  opposite  pheno- 
mena may  occur.  On  the  other  hand,  however,  we  may  remark, 
that  the  increased  thickness  of  all  these  organs,  at  this  point,  is  of 
much  utility,  when  we  wish  to  form  an  artificial  nose  at  the  ex- 
pense of  the  skin  of  the  forehead. 

HI.  The  Muscles. 

These  are,  in  the  middle  and  superiorly,  the  pyramidalis  nasi ; 
transversely  and  laterally,  the  compressor  narium  (transversalis 
vel  triangularis  nasi),  crossed  by  the  levator  communis.  The  de- 
pressor alae  nasi  also  appertains  to  this  region,  but  it  may  well  be 
classed  with  those  of  the  labial  region.  The  first  three  seem  to 
be  confounded  in  the  nasal  aponeurosis,  and  are  of  no  importance 
in  surgery ;  it  is  only  necessary  to  recollect  the  direction  of  their 
fibres,  that  we  may  avoid,  in  the  performance  of  operations,  cut- 
ting across  them. 

iv.  The  Arteries. 

They  are  large  and  numerous,  in  proportion  to  the  size  of  the 
organ.  At  the  root  of  the  nose  we  observe  the  nasal  branch  of 
the  ophthalmic,  which  anastomoses  with  the  facial ;  upon  the  dor- 


OF   THE   HEAD.  39 

sum,  the  branches  which  originate  from  the  latter,  which  also 
sends  some  twigs  to  the  septum  and  alae ;  some  small  branches 
from  the  coronary  and  infra-orbital ;  lastly,  in  the  lobule  we  find 
the  ethmoidal  coming  from  the  interior  of  the  nose. 

It  is  on  account  of  this  free  supply  of  blood  that,  when  cerebral 
congestions  and  other  affections  of  the  head  exist,  the  nose  is 
habitually  red  in  some  individuals. 

This  same  disposition  also  accounts  for  the  success  attendant 
upon  the  making  of  new  noses,  whether  according  to  the  Indian 
method,  or  that  of  Tagliacozzi. 

v.  The  Veins. 

Almost  all  of  them  pass  into  the  angularis,  which  also  receives 
the  frontal  veins ;  whence  we  may  account  for  the  success  which 
the  ancients  derived  from  bleeding  at  this  point  in  certain  affec- 
tions of  the  nose  and  cranium.  Their  capillaries  are  numerous ; 
but  as  they  are  imbedded  in  the  subcutaneous  layer,  which  is 
dense,  the  circulation  through  them  is  not  very  free.  To  this 
cause,  perhaps,  instead  of  arterial  action,  we  may  attribute  the 
red  colour  of  the  nose  in  some  persons. 

vi  The  Lymphatics. 

They  follow  the  track  of  the  arteries,  and  generally  enter  the 
glands  beneath  the  jaw ;  whence  tumefaction  of  the  latter  in  some 
affections  of  the  nose. 

vn.  The  Nerves. 

They  come  from  the  ophthalmic  of  Willis  and  the  superior 
maxillary  nerve,  and  are,  superiorly,  a  filament  of  termination 
from  the  internal  nasal,  and  another  twig  from  the  external  nasal 
branch  of  the  frontal ;  upon  the  sides  numerous  branches  from 
the  infra-orbitar  ;  upon  the  dorsurn  and  in  the  lobule,  the  ethmoi- 
dal filament  of  the  nasal  branch  of  the  ophthalmic  which  has  tra- 
versed the  nostrils. 

These  nervous  supplies  sufficiently  account  for  the  acute  sensi- 
bility of  the  nose ;  the  sympathetic  affections  which  its  inflamma- 


40 


OP   THE    HEAD. 


tions  may  produce,  and  the  violent  pains  which  frequently  accom 
pany  the  latter.  These  phenomena  are  also  aggravated  by  the 
compact  structure  of  its  tissues. 

viii.  The  Bones  and  Cartilages. 

The  first  are  the  whole  of  the  nasal  bones,  and  almost  the  whole 
of  the  nasal  process  of  the  superior  maxillary  bone.  The  rela- 
tions of  this  nasal  process  with  the  lachrymal  passages,  its  articu- 
lation with  the  os  frontis  and  ossa  nasi,  the  disposition  of  the  lat- 
ter in  relation  to  the  cranium  and  nasal  fossa),  readily  account  for 
the  cerebral  disturbances,  affections  of  the  orbit,  of  the  lachrymal 
sac,  &c.,  produced  by  the  fractures,  exostoses  or  other  diseases 
of  the  bones  appertaining  to  the  nasal  eminence.  These  bones 
being  somewhat  thick  and  very  short,  cannot  be  fractured  but  by 
a  direct  cause,  and  the  force  necessary  to  produce  this  accident 
renders  the  wound  more  severe  by  the  injury  done  to  the  soft 
parts  than  by  the  fracture  itself.  As  they  are  not  supported  in 
the  nasal  fossa,  they  are  readily  displaced ;  and,  if  we  do  not  take 
the  necessary  precautions,  a  disagreeable  deformity,  impeded 
respiration,  alteration  in  the  voice  and  in  the  sense  of  smell  will 
ensue.  They  also  differ  in  length,  thickness  and  degree  of  ele- 
vation which  renders  them  more  or  less  liable  to  fractures,  and 
produces  the  varieties  in  the  form  of  the  nose. 

The  second  are  the  triangular  cartilages,  those  of  the  circum- 
ference of  the  nostrils,  and  of  the  alse ;  then  the  anterior  margin 
of  the  septum.  The  latter  is  encased  between  the  others  in  such 
a  manner  that  it  would  be  possible  to  extract  a  part  of  it,  if  it 
was  diseased,  without  penetrating  into  the  nasal  fossae.  In  order 
to  do  this  it  would  be  sufficient  to  incise  the  lobule  and  septum 
upon  the  median  line,  and  then  detach  the  internal  branch  of 
each  cartilage  of  the  alse.  It  is  at  the  place  where  these  last  unite 
with  the  lateral  cartilage  that  we  observe  the  most  remarkable 
depression  which  exists  upon  the  nose.  A  filament  of  the  nasalis 
internus  (naso-ldbaire]  nerve  passes  between  the  inferior  border 
of  the  os  nasi  and  the  triangular  cartilage.  If  this  nerve  was 
the  seat  of  neuralgia,  it  would  not  be  difficult  to  discover  and 
divide  it.  All  these  elastic  laminae  are  covered  by  a  very  dense 


OF   THE   HEAD.  41 

fibrous  perichondrium,  which  unites  them  to  the  surrounding  parts 
and  is  continued  upon  the  bones  forming  their  periosteum. 

Syphilitic  affections,  cancerous  warts,  &c.  sometimes  render  it 
necessary  to  amputate  the  free  extremity  of  the  nose.  The  pre- 
ceding anatomical  remarks  show  us  that  this  amputation  may  be 
performed  as  far  as  the  place  where  the  bones  unite  with  the 
cartilages.  It  is  on  account  of  this  amputation,  or  the  loss  of  the 
lobule  by  accident  or  disease,  that  the  formation  of  a  new  nose 
(Rynoplastique)  has  been  recommended,  whether  for  the  purpose 
of  correcting  a  hideous  deformity,  or  for  restoring  the  sense  of 
smell,  which,  according  the  experiments  of  M.  Magendie,  is  lost 
when  the  extremity  of  the  nose  has  been  removed.  Professor 
Beclard  has  remarked,  that  a  metallic  artificial  nose  equally  re- 
established the  olfactive  function. 

The  nose  is  one  of  the  parts  of  the  face  which  has  the  greatest 
influence  over  the  expression  of  the  physiognomy ;  it  is  also  a 
powerful  index  of  disease ;  but  as  this  more  properly  belongs  to 
semiology,  we  will  not  deviate  from  our  subject  to  enter  into 
details  of  these  peculiarities. 

The  following  is  the  order  of  super-position  in  this  region :  1st, 
the  skin ;  2d,  the  fibro-cellular  layer ;  3d,  the  muscles  and  apo- 
neurosis;  the  vessels  and  nerves  are  distributed  among  these 
different  tissues;  4th,  the  periosteum  and  perichondrium;  5th, 
the  bones  and  cartilages. 

Sect.  3.  Orbital  Region. ' 

This  region  comprehends  the  whole  of  the  apparatus  of  vision, 
and  the  greater  part  of  the  lachrymal  apparatus.  It  is  bounded 
by  the  circumference  of  the  orbit,  and  consequently  has  the  nasal 
region  internally,  the  temporal  externally,  the  frontal  superiorly, 
and  the  zygomato-maxillary  inferiorly.  It  presents  for  our  con- 
sideration the  orbital  arches,  the  eyelids,  the  palpebral  angles,  the 
eye,  and  the  orbit. 

i.  The  Supra-orbital,  or  Superciliary  Arcade. 

The  skin  which  enters  into  the  composition  of  this  arcade  is 

6 


i'2  OF    THE    HEAD. 

thicker  than  that  of  the  eyelids,  and  thinner  than  that  of  the  fore- 
head ;  it  is  supple,  extensible,  and  gives  insertion  to  the  hairs  oi 
the  eyebrow.  These  hairs  are  generally  darker  than  those  of  the 
scalp ;  they  serve  to  diminish  the  intensity  of  the  rays  of  light 
which  pass  to  the  eye,  and  to  direct  the  course  of  the  sweat  to- 
wards the  root  of  the  nose.  This  remark  enables  us  to  compre- 
hend why  their  falling  out,  or  destruction,  so  frequently  induces 
inveterate  ophthalmia  or  other  diseases  of  the  eye. 

The  volume  of  the  eyebrow  depends  upon  several  causes :  in 
the  first  place,  upon  the  size  and  number  of  the  hairs ;  next,  upon 
the  thickness  of  the  soft  parts  on  which  they  rest,  and  especially 
upon  the  prominence  of  the  osseous  arch.  We  will  refer  to  this 
when  we  come  to  treat  of  each  of  these  parts  separately.  There 
are  a  great  number  of  follicles  between  the  roots  of  the  hairs 
especially  towards  the  nose. 

The  subcutaneous  cellular  tissue  forms  a  dense,  thick,  and  fila- 
mentous layer,  iii  which  we  meet  with  adipose  vesicles.  This 
layer  presents  nearly  the  same  characters  as  that  which  lines  the 
hairy  scalp ;  the  same  surgical  considerations,  therefore,  are  appli- 
cable to  it. 

The  muscles  are,  the  superior  arches  of  the  orbicularis  palpe- 
brarum,  which  follows  the  same  direction  as  the  arcade  ;  the 
inferior  portion  of  the  frontalis  which  descends  perpendicularly 
behind  the  preceding ;  internally,  a  part  of  the  pyramidalis,  and 
lastly,  the  corrugator  supercilii.  This  last,  the  most  important 
of  all,  passes  obliquely  upwards  and  outwards  from  the  internal 
orbitary  process,  between  the  frontalis  and  orbicularis  palpebra- 
rum,  in  order  to  terminate  in  the  skin. 

These  muscles  are  not  in  relation  with  any  aponeurosis ;  the 
cellular  tissue  which  separates  them  is  loose  and  lamellated ; 
whence  it  follows  that  abscesses  may  form  here,  and  that  in  con- 
sequence of  wounds,  of  whatsoever  nature  they  may  be,  the  pus 
burrows  between  these  organs  and  the  bones :  therefore,  if  sup- 
puration is  imminent,  we  should  not  reunite  them  immediately, 
and  when  the  matter  has  formed  evacuate  it  immediately. 

The  arteries  of  the  superciliary  arcade  are  not  proper  to  it. 
for  the  most  part,  they  only  traverse  it.  They  are  :  externally,, 
some  twigs  from  the  anterior  temporal  branch ;  at  the  inner  third- 


OF   THE  HEAD. 


43 


some  small  branches  from  the  supra-orbital,  the  trunk  of  which 
ascends  between  the  frontalis  and  corrugator  muscles ;  internally, 
ramusculi  from  the  nasal. 

Consequently,  a  wound  inflicted  about  one  inch  above  and 
external  to  the  tendon  of  the  orbicularis,  may  occasion  a  trouble- 
some haemorrhage.  In  such  a  case,  if  the  artery  is  divided  be- 
tween the  muscles,  it  may  be  easily  tied,  because  the  cellular 
tissue  here  is  lamellated,  and  of  slight  density.  Above  the  cor- 
rugator, on  the  contrary,  it  would  be  better  to  compress  it,  be- 
cause it  would  be  difficult  to  pinch  up  the  vessel  in  the  subcuta- 
neous layer. 

The  superficial  veins  require  no  particular  notice  here  ;  the 
others  follow  the  course  of  the  arteries ;  the  frontal,  however, 
should  be  attended  to,  wiiich  descends  along  the  median  line  be- 
tween the  two  orbital  arcades.  We  have  already  seen  this  vein 
in  the  frontal  region,  and  will  soon  find  it  again  in  the  great  an- 
gle. 

It  is  proper  to  note  that  the  lymphatic  vessels  do  not  all  enter 
the  same  glands.  The  most  internal,  like  those  of  the  forehead, 
follow  the  blood  vessels  of  the  face,  and  run  into  the  submaxillary 
lymphatic  glands  ;  whilst  those  of  the  external  portion  direct 
their  course  towards  the  fore  part  of  the  ear.  This  disposition 
leads  us  to  believe  that  diseases  of  the  head  of  the  eyebrow,  will 
affect  the  glands  beneath  the  jaw  ;  and  those  of  its  external  half, 
the  absorbent  glands  of  the  parotideal  region. 

The  nerves  are  the  most  important  parts  which  we  have  to  con- 
sider here.  Externally,  we  find  one  or  more  filaments  of  the  fa- 
cial, which  come  to  anastomose  with  the  supra-orbital ;  quite 
internally,  some  twigs  from  the  nasalis  internus,  which  inosculate 
with  the  frontalis ;  but  the  largest  are  the  two  cords  of  the  supra- 
orbital,  which  sometimes  come  out  of  the  orbit  together  through 
the  supra-orbital  foramen ;  more  frequently,  however,  the  small 
branch  passes  between  the  cartilaginous  pulley  of  the  trochlearis, 
and  the  internal  orbitary  process.  These  nerves  appear  to  be  the 
seat  of  those  acute  pains  known  by  the  name  of  frontal  neural- 
gia ;  and  it  is  for  this  reason  that  the  superciliary  nerve  is  fre- 
quently divided  for  the  purpose  of  removing  these  pains.  By 
this  means,  these  pains  have  been  sometimes  suspended,  but  as 
they  have  occasionally  returned,  their  re-appearance  has  been 


44  OF   THE    HEAD. 

attributed  to  the  anastomosis  of  the  divided  branch  with  those  in 
its  vicinity.  Notwithstanding  this  explanation  may  appear  satis- 
factory, it  is  not  certain  that  it  is  correct,  because  in  these  cases, 
the  two  divided -extremities  of  the  nerve  may  have  become  re- 
united, and  the  nervous  influence  thereby  transmitted  along  the 
same  cord.  Therefore,  if  this  operation  is  decided  on,  we  should 
not  content  ourselves  with  a  simple  division  of  the  diseased  nerve, 
but  likewise  remove  a  portion  of  it.  Furthermore,  in  order  to 
reach  it  easily,  we  must  seek  for  it  immediately  as  it  comes  out 
from  the  supra-orbital  notch,  because,  in  this  situation,  we  would 
have  to  divide  only  the  skin,  the  orbicularis  muscle,  and  two  thin 
layers  of  cellular  tissue.  In  order  to  find  this  notch,  we  have  I 
only  to  carry  the  finger  along  the  border  of  the  osseous  arch  from 
its  internal  towards  its  external  extremity,  and  the  first  depression 
we  meet  with,  will  be  that  which  includes  the  nerve.  It  is  gen- 
erally situated  about  one  inch  external  to  and  above  the  direct 
tendon  of  the  orbicularis  palpebrarum.  During  the  operation, 
we  must  keep  the  eye-brow  firmly  elevated ;  for  its  muscle,  in 
contracting,  would  draw  it  down,  and  thereby  interfere  with  the 
free  play  of  the  instrument. 

The  skeleton  of  this  arcade  appertains  entirely  to  the  os  frontis. 
Its  external  half  generally  forms  a  thin  edge :  its  internal  is  more 
rounded,  and  it  is  upon  this  that  the  head  of  the  eye-brow  rests  : 
it  is  more  or  less  prominent,  on  account  of  the  frontal  sinus  which 
corresponds  to  it. 

External  violence  acting  upon  this  arch,  is  much  less  liable  to 
occasion  its  fracture  than  that  of  the  vault  of  the  orbit  which  is 
much  thinner.  As  the  eye-brow  is  frequently  the  seat  of  encyst- 
ed tumours  (loupes),  in  which  hairs  are  sometimes  observed,  certain 
authors  have  supposed  that  the  presence  of  the  latter  is  merely 
owing  to  a  simple  deviation  from  their  natural  direction  (Beclard) ; 
others,  to  an  unnatural  elongation  of  the  small  root  of  those  of 
the  eye-brow ;  whereas  M.  Laennec  says  that  they  are  accidental 
productions. 

ii.  T/te  Superior  Palpebra. 

This  eye-lid  is  continuous,  superiorly,  with  the  eye-brow ;  is 
longer,  broader,  and  more  curved  than  the  inferior,  and  the  skin 


OP  THE   HEAD.  45 

xvhich  enters  into  its  composition  is  very  delicate  and  very  exten- 
sible. The  layer  of  lamellated  tissue  is  very  lax,  and  never  con- 
tains fat ;  it  encloses  a  fibrous  plate,  the  external  half  of  which  is 
sometimes  very  strong  :  this  is  the  palpebral  ligament.  This  lig- 
ament is  attached  to  the  external  half  of  the  circumference  of 
the  orbit,  and  internally  is  converted  into  a  cellular  structure  of 
greater  or  less  density. 

The  aponeurotic  expansion  of  the  levator  palpebrae  superioris 
muscle,  the  tarsal  cartilage,  the  meibomian  glands  and  conjunctiva 
also  enter  into  the  composition  of  the  upper  eye-lid,  upon  the  free 
border  of  which  we  observe,  in  the  four  external  fifths,  anteriorly 
the  cilia ;  posteriorly,  the  orifice  of  the  palpebral  follicles  ;  at  the 
union  of  this  portion  with  the  internal  fifth,  the  punctum  lachry- 
male,  then  its  canal ;  finally,  between  the  conjunctiva  and  the  in- 
ternal surface  of  the  tarsal  cartilage,  near  the  convex  margin  of 
the  latter,  the  opening  of  the  ducts  of  the  lachrymal  gland. 

in.  The  Inferior  Palpebra. 

This  is  shorter  and  narrower  than  the  preceding,  and  is  contin- 
uous with  the  inferior  orbital  arcade.  Its  constituent  parts,  like 
those  of  the  superior,  are  the  skin,  which  is  equally  delicate ;  a 
lamellated  layer,  in  which  a  few  adipose  vesicles  are  sometimes 
developed  ;  the  inferior  half  of  the  palpebral  ligament ;  very 
rarely  a  depressor  muscle  ;  the  tarsal  cartilage  ;  some  fine  cellu- 
lar tissue,  and  the  conjunctiva.  The  free  border,  less  concave 
than  that  of  the  superior,  does  riot  otherwise  differ  from  it. 

Each  element  of  these  membranous  veils  possesses  some  pe- 
culiarity which  it  is  proper  to  point  out. 

A.  The  Skin. 

It  is  extremely  thin,  soft  and  vascular,  which  causes  it  to  as- 
sume a  bluish  or  livid  appearance  in  certain  indispositions  ;  it  is 
never  covered  with  hairs  ;  in  old  people,  it  is  wrinkled  in  arcs  of 
circles,  and,  in  all  subjects,  it  is  but  loosely  united  to  the  subja- 
cent laminated  tissue.  It  is  owing  to  this  looseness  of  texture 
that  the  cutaneous  tissue  of  the  eye-lids  sometimes  elongates  suf- 
ficiently to  admit  of  the  inversion  of  the  eye-lids,  thereby  produc- 


40  OF    THE    HEAD. 

ing  ophthalmia,  which  cannot  be  cured  but  by  removing  a  certain 
portion  of  the  skin  thus  relaxed. 


B.  The  Laminated  Tissue. 

This  element  never  contains  fat,  from  which  circumstance  the 
eye-lids  appear  depressed  in  those  who  are  corpulent.  Its  la- 
mellae are  very  loosely  arranged,  whence  serous  infiltrations  fre- 
quently and  speedily  form  in  this  tissue.  It  is  also  owing  to  the 
same  circumstance  that  such  extensive  ecchymoses  occur  here 
after  the  application  of  leeches  ;  therefore  it  would  be  better, 
in  many  cases,  to  apply  them  to  the  conjunctiva  itself,  which  we 
have  frequently  done  with  success.* 

The  cellular  tissue  which  unites  the  orbicularis  palpebrarum 
muscle  to  the  ligament  of  the  eye  lids,  the  tarsal  cartilage  or  to 
the  conjunctiva,  although  lamellated,  is  more  dense  and  does  not 
admit  of  infiltrations.  It  is  between  the  laminae  of  this  cellular 
tissue  that  encysted  tumours  of  the  eye-lids  are  developed  ;  conse- 
quently, as  these  tumours  are  nearer  to  the  conjunctiva,  than  the 
skin,  it  is  better  to  expose  them  upon  the  inner  surface  of  the 
palpebra. 

C.  The  Muscles. 

We  only  find  in  the  inferior  eye-lid  the  corresponding  arches 
of  the  orbicularis,  whereas  the  superior  has  in  addition  its  levator 
muscle  ;  whence  the  great  mobility  of  the  latter,  whilst  the  former 
is  scarcely  susceptible  of  any  movement.  The  fibres  of  the  orbi- 
cularis are  paler,  thinner  and  less  curved,  the  nearer  we  ap- 
proximate the  edge  of  the  palpebra.  Their  insertion  will  be 
examined  when  we  come  to  speak  of  the  great  angle. 

D.  The  Palpebral  Ligament. 

It  is  attached  to  the  external  half  of  the  two  orbital  arches,  and 
is  situated  between  the  orbicularis  muscle  and  conjunctiva ;  it 
seems  to  be  continuous  with  the  external  extremity  of  the  tarsal 

•  Xouveau  Journal,  etc.  1821. 


OF    THE    HEAD.  47 

cartilages.  Its  existence  on  the  outer  side  of  the  orbit  renders 
inflammations  there  more  painful,  on  account  of  the  resistance 
which  it  opposes  to  the  tumefaction  of  the  parts,  and  it  also  repres- 
ses, for  a  length  of  time,  the  external  projection  of  tumours  which 
form  betweenit  and  the  conjunctiva,  or  in  the  cavity  of  the  orbit. 

E.  The  Tarsal  Cartilages. 

The  tarsal  cartilages  are  much  thinner  at  their  convex  border 
than  towards  the  palpebral  aperture.  In  the  first  direction  they 
are  connected  to  the  ligament  of  the  eye-lids,  and,  besides,  in  the 
superior  lid,  to  the  levator  muscle  ;  in  the  second,  they  are  envel- 
oped only  by  the  skin  and  the  mucous  membrane  to  which  they 
are  very  intimately  united :  from  which  circumstance  the  slight 
inflammations  which  originate  here  are  very  painful  and  produce 
the  stye. 

The  tarsal  cartilage  is  covered  by  the  orbicularis  muscle,  and 
rests  upon  the  conjunctiva,  from  which  it  is  separated  by  the 
glands  of  M  eibomius  only.  That  of  the  upper  lid  is  also  in  relation 
with  the  ducts  of  the  lachrymal  gland ;  its  breadth  from  above 
downwards,  is  five  lines ;  its  length,  transversely,  from  five  to  six 
lines ;  the  inferior  is  also  six  lines  transversely,  but  only  two 
lines  from  above  downwards.  Their  posterior  surface  is  concave, 
and  moulded  upon  the  convexity  of  the  eye ;  finally,  these  plates 
form,  properly  speaking,  the  skeleton  of  the  eye-lids. 

F.  The  Conjunctiva. 

This  membrane  is  dense,  very  firmly  adherent  to  the  free  margin, 
and  about  as  much  as  a  line  upon  the  internal  surfaces  of  the  pal- 
pebrae ;  it  then  becomes  soft  and  supple,  in  proportion  as  it  ap- 
proximates its  point  of  reflexion  upon  the  globe  ;  it  is  supposed  to 
to  dip  into  the  orifices  of  the  ducts  of  the  lachrymal  gland,  which 
form  an  arch  towards  the  point  corresponding  to  the  convex  mar- 
gin of  the  tarsai  cartilages.  As  this  membrane  becomes  much 
less  adherent  in  approximating  the  eye,  than  it  is  near  the  free 
margin  of  the  palpebral  veils,  it  is  much  better,  when  we  wish  to 
make  the  excision  for  the  cure  of  ectropium,  to  cut  at  a  little 
distance  from,  rather  than  too  near,  this  margin. 


48  OF   THE    HEAD. 


G.  The  Palpebral  Follicles  or  Glands  of  Meibomius 

These  small  granulations  are  collected  in  perpendicular  lines 
upon  the  grooves  which  the  ocular  surface  of  the  tarsal  cartilage 
presents ;  they  all  open  upon  the  posterior  crest  of  the  free  margin 
of  the  palpebrse.  Perhaps  the  conjunctiva  penetrates  into  their 
orifices.  It  is  in  the  ophthalmia  depending  upon  the  affection  of 
these  small  organs  that  the  dessicative  ointments  of  Desault, 
Regent,  etc.,  seem  to  have  proved  beneficial.  For  this  purpose 
the  unguent  should  be  applied  over  the  entire  border  of  the  palpe- 
bra,  and  not  simply  introduced  at  one  of  the  angles. 

H.  The  Arteries. 

Internally  we  find  the  two  internal  palpebral  arteries,  furnished 
by  the  ophthalmic  ;  externally,  the  two  external  palpebral,  derived 
from  the  lachrymal ;  superiorly,  some  twigs  from  the  supra-orbital, 
and  inferiorly,  some  ramusculi  from  the  infra-orbital  and  facial 
arteries. 

The  first  four  form  two  arcades  which  have  the  same  direction 
with  the  curvature  of  the  eye-lids,  and  are  situated  four  or  five 
lines  distant  from  the  free  border,  behind  the  orbicularis  muscle. 
These  arches  resemble  the  coronary  arteries  of  the  lips,  and  we 
should  pay  attention  to  their  volume  and  situation  in  all  operations 
in  which  the  eye  lids  are  concerned.  They  are  sufficiently  re- 
mote from  the  margin  of  these  veils  to  permit  us  to  remove  a 
considerable  portion  of  them,  in  cancerous  or  other  diseases,  by 
following  the  advice  given  by  MM.  Dubois,  Richerand,  and  Du- 
puytren,  without  wounding  the  vessels.  On  the  contrary,  if 
according  to  the  ancient  method,  we  are  obliged  to  include  the 
morbid  tumour  in  a  triangle  of  sound  tissue,  resembling  the  form 
of  a  V  reversed,  these  arteries  will  necessarily  be  divided. 

J.  TJie  Veins. 

Almost  all  of  them  pass  to  the  ophthalmic,  a  few  only  into  the 
angular  vein ;  they  are  larger  than  the  arteries,  and  communicate 
directly  with  those  of  the  brain :  from  this  communication  we 


OF   THE    HEAD.  49 

may  in  part  account  for  the  pain,  redness,  and  inflammation  of  the 
eyes  which  we  so  frequently  observe  in  diseases  of  the  encephalon. 

K.  The  Lymphatics. 

Those  of  the  external  portion  of  the  superior  palpebra  pass  to 
the  parotideal  region,  all  the  others  cross  the  face,  directing  their 
course  below  the  jaw. 

L.  The  Nerves. 

We  find,  internally,  and  parallel  to  the  direction  of  the  arteries, 
the  palpebral  branches  of  the  nasalis  internus ;  externally,  fila- 
ments from  the  lachrymal  and  a  few  from  the  facial ;  superiorly 
it  is  also  supplied  by  the  two  branches  of  the  frontal,  and  the 
inferior  palpebra  receives  some  from  the  infra-orbital  nerve. 

It  is  to  this  free  supply  of  nerves  that  the  eye-lids  owe  their 
exquisite  sensibility;  a  sensibility  which  is  also  increased,  to- 
wards the  free  margin,  by  the  compact  texture  of  the  tissues. 
This  last  peculiarity  seems  to  us  to  explain  the  reason  why  the 
application  of  leeches  to  the  conjunctiva  is  very  painful,  when 
made  too  near  the  palpebral  border,  whilst  they  are  scarcely  felt 
when  applied  at  a  greater  distance  from  it. 

M.  The  Cilice. 

These  are  the  hairs  implanted  into  the  anterior  crest  of  the 
free  margin  of  the  eye-lids  ;  they  are  continued  only  as  far  as  the 
punctum  lachrymale,  and,  when  the  eyes  are  open,  form  a  curve, 
the  concavity  of  which  looks  towards  the  orbital  arches.  They 
are  arranged  in  two  or  three  rows,  and  may  deviate,  in  such  a 
manner,  as  to  pass  towards  the  eye  instead  of  taking  the  opposite 
direction.  Their  roots  are  surrounded  by  follicles,  which,  when 
diseased  frequently  cause  the  eye-lashes  to  fall  out.  Their  bulbs 
receive  numerous  filaments  from  the  palpebral  nerves,  which 
may,  in  general,  be  easily  traced  to  the  piliferous  ampululo?. 


50  01     THE    HEAD, 

N.  The  Infra-Orbital  Arch. 

It  is  with  this  that  the  inferior  eye-lid  is  continuous  ;  it  presents 
successively  from  the  surface  towards  the  deep-seated  parts,  1st. 
the  skin  already  stronger  and  less  extensible ;  '2d.  a  cellulo-adi- 
pose  layer  of  more  or  less  thickness ;  3d.  a  portion  of  the  orbicu- 
laris  muscle ;  4th.  a  second  cellular  layer,  containing  adipose 
vesicles ;  5th.  the  periosteum ;  6th.  the  bones,  upon  which  we 
observe  the  zygomato -maxillary  suture.  These  bones  being  thick 
and  compact  they  are  seldom  fractured  ;  but  the  arch  which  they 
form  is  of  great  assistance,  in  certain  cases,  in  finding  the  lach- 
rymal groove.  We  will  resume  this  subject  when  we  come  to 
speak  of  the  great  angle. 

O.  Of  the  Temporal  Angle  of  the  Palpebrcp. 

Through  the  skin,  in  this  situation,  we  feel  a  pretty  deep  de- 
pression, which  is  limited,  superiorly,  by  the  external  orbitary 
process  of  the  os  frontis ;  inferiorly  by  the  frontal  angle  of  the 
os  make.  The  palpebral  commissure  is,  in  general,  two  or  three 
lines  on  the  inner  side  of  these  bones,  and  the  eye  appears  to  be 
larger  or  smaller  in  proportion  to  the  distance  of  this  commissure 
from  them,  which  is  then  owing  to  the  slit  in  the  eye-lids  being 
more  or  less  extensive. 

As  the  margins  of  the  palpebrae  touch  each  other  towards  their 
external  extremities  even  when  half  open,  if  we  are  not  particu- 
lar in  separating  them  frequently,  when  inflamed  or  excoriated, 
unnatural  adhesions  will  form  between  them. 

In  this  angle,  we  find,  1st.  the  skin  and  the  lax  cellular  tissue 
common  to  the  palpebrae ;  2d.  the  external  extremity  of  the 
fibres  of  the  orbicularis,  and  the  raphe  which  results  from  their 
intersection ;  3d.  the  strongest  portion  of  the  palpebral  ligament ; 
4th.  the  conjunctiva ;  5th.  the  origin  of  the  two  external  palpe- 
bral arteries ;  6th.  the  termination  of  the  lachrymal  nerve ;  7th. 
some  filaments  from  the  facial,  and  8th.  the  zygomato-frontal 
(external  transverse)  suture. 

In  some  persons,  and  especially  the  aged,  the  skin  of  the  tem- 
poral angle  presents  many  convergent  folds,  which  should  be 


OF    THE    HEAD.  .")i 

attended  to  when  we  make  incisions  into  this  part.  Exclusive 
of  these  wrinkles,  we  may  incise  in  all  directions  without  danger, 
since  the  muscle  has  no  fixed  point  on  this  side  and  there  are  no 
important  nerves  or  vessels  to  be  avoided.  However,  it  should 
be  remarked  that  the  conjunctiva  is  somewhat  removed  from 
the  palpebral  ligament,  for  it  might  happen  that  wounds,  pene- 
trating into  this  space,  may  be  rendered  dangerous  from  the 
facility  with  which  inflammation  and  pus  penetrate  into  the  cavi- 
ty of  the  orbit. 

P.  The  Great  Angle. 

This  angle  is  one  of  the  most  important  parts  of  the  orbital 
region,  both  on  account  of  the  frequency  of  its  diseases  and  of 
the  operations  here  performed. 

This  part,  connecting  the  eye-lids  to  the  nose,  is  covered  by  a 
skin  which  partakes  of  the  characters  of  both  of  these  regions. 
It  is  much  less  extensible  than  upon  the  eye-lids,  but  thinner 
than  upon  the  nose :  on  account  of  its  tenuity,  abscesses  which 
form  beneath  soon  perforate  it,  and  tumours  which  raise  it  sel- 
dom become  of  large  size  without  disorganizing  it. 

Beneath  the  skin  is  the  common  cellular  layer. 

Next  comes  the  orbicularis  palpebrarum  muscle,  which  here 
deserves  great  attention.  Inferiorly,  its  fibres  are  attached  to 
the  external  surface  of  the  ascending  process  of  the  superior 
maxillary  bone,  where  they  cover  a  small  portion  of  the  levator 
labii  superioris  alaequae  nasi.  Superiorly,  some  of  these  fibres  are 
fixed  to  the  internal  orbital  process  of  the  os  frontis,  and  in  the 
middle  they  originate  from  a  tendon  which  requires  particular 
examination. 

This  tendon  is  about  one  line  in  breadth  and  three  in  length,  is 
flattened  and  attached  to  the  external  labium  of  the  lachrymal 
groove ;  it  bifurcates  in  terminating  in  the  eye-lids  in  order  to 
become  continuous  with  the  tarsal  cartilages,  and  rests  upon  the 
fibrous  portion  of  the  lachrymal  sac,  in  the  formation  of  which  it 
seems  to  concur.  We  designate  the  tendinous  portion,  properly 
so  called,  the  direct  tendon,  and  the  fibres  which  it  furnishes  to 
the  sac,  or  which  it  receives  from  it,  the  reflected  tendon.  The 


OF   THE   HEAD. 

transverse  position  of  the  direct  tendon  divides  the  sac,  as  it 
were,  into  a  superior  and  an  inferior  portion. 

The  inferior  is  seen  in  a  triangular  space  with  an  external 
base,  the  superior  side  of  which  is  straight  arid  formed  by  the 
tendon.  The  inferior  side  of  this  triangle  is  concave  and  formed 
by  the  external  labium  of  the  lachrymal  groove,  and  the  anterior 
border  of  the  superior  maxillary  bone.  It  is  in  the  summit  of 
this  space  that  we  must  introduce  the  point  of  the  bistoury  in 
order  to  penetrate  easily  into  the  lachrymal  sac. 

The  direct  tendon  receives  the  fleshy  fibres  of  the  two  palpe- 
brae,  and  serves  as  their  fixed  point  upon  the  nose ;  consequently, 
if  we  divided  this  fibrous  bandelet,  ectropium  would  follow,  as 
was  the  case  in  the  operation  for  fistula  lachrymalis,  recom- 
mended by  Wolhouse. 

We  will  speak  of  the  superior  portion  when  considering  the 
lachrymal  passages. 

Q.  The  Puncta  and  Lachrymal  Canals. 

These  organs  are  situated  in  the  rounded  and  straight  portion 
of  the  free  margin  of  the  palpebrae.  The  puncta,  or  external 
orifices  of  the  ducts  consist  of  a  small  fibro-cartilaginous  ring, 
and  are  situated  at  the  internal  extremity  of  the  posterior  crest 
of  the  concave  portion  of  the  free  border :  they  dip  perpendicu- 
larly into  the  eye-lid,  to  the  depth  of  about  a  line,  and  afterwards 
form  a  rectangular  turn  and  become  continuous  with  the  canals. 

When  the  lids  are  open,  these  orifices  look  obliquely  between 
the  globe  of  the  eye  and  the  caruncula  lachrymalis  ;  when  closed, 
they  look  directly  backwards.  On  account  of  this  disposition, 
therefore,  when  we  wish  to  introduce  an  instrument  into  them, 
we  must  evert  the  lid,  and  then  it  will  fall  perpendicularly  into 
the  aperture.  The  canals  then  pass  towards  the  commissure, 
following  exactly  the  direction  of  the  straight  portion  of  the  pal- 
pebral  border.  They  sometimes  unite  before  they  enter  the 
lachrymal  sac,  into  which  they  then  terminate  by  a  common 
opening ;  and  again  they  only  approximate  each  other  and  open 
separately  into  it. 

The  lachrymal  canal  is  situated  in  the  posterior  part  of  the 
margin  of  the  palpebra ;  therefore,  it  is  less  exposed  to  the  action 


OP   THE   HBAD.  53 

of  foreign  bodies :  it  is  separated  from  the  eye  and  the  caruncle 
by  the  tunica  conjunctiva  only,  and  appears  to  be  merely  a  pro- 
longation of  the  mucous  membrane  of  the  nose.  From  this  it 
follows  that  its  ocular  paries  is  very  thin  and  soft,  so  that  it  is 
liable  to  be  perforated  by  the  stylet,  in  the  operations  proposed 
by  Anel,  Mejan,  etc.,  if  we  do  not  pass  it  in  the  proper  direction. 
The  superior  canal  being  more  easily  placed  in  a  direction 
parallel  to  the  nasal  duct  by  raising  the  palpebra  towards  the 
head  of  the  eye-brow,  it  should  be  preferred  for  the  purpose  of 
introducing  probes,  setons,  or  other  foreign  bodies  into  the  lach- 
rymal passages.  It  is  by  the  inferior,  on  the  contrary,  that  we 
should  throw  in  our  injections,  on  account  of  its  transverse  posi- 
tion and  greater  degree  of  immobility,  on  the  one  hand,  and,  on 
the  other,  because  we  can  easily  obtain  a  point  of  support  upon 
the  os  malae. 

R.  The  Lachrymal  Sac. 

This  sac  seems  to  form  the  superior  half  or  termination  of  a 
canal  which  comes  from  the  nose.  It  is  crossed  anteriorly,  as 
we  have  already  observed,  by  the  direct  tendon  of  the  orbicu- 
laris,  above  which  it  terminates  in  a  cul-de-sac,  and  is  formed  by  a 
cellulo-fibrous  canal,  four  lines  in  length  and  from  two  to  three 
lines  in  breadth.  Internally,  it  lies  upon  the  lachrymal  groove, 
where  it  becomes  blended  with  the  periosteum,  and  to  which  it 
is  firmly  adherent ;  externally,  it  is  separated  from  the  caruncle 
and  conjunctiva  by  a  fibrous  expansion,  which  is  fixed,  on  the  one 
hand,  to  the  posterior  margin  of  this  gutter,  and  on  the  other,  to 
the  posterior  surface  of  the  direct  tendon  of  the  orbicularis 
muscle,  from  which  it  originates,  and  of  which  it  constitutes  the 
reflected  tendon.  This  expansion  is  only  found  opposite  to  and 
above  the  direct  tendon,  which  explains  in  part  why  the  lachry- 
mal tumour  is  more  fully  developed  below  this  fibrous  bandelet, 
in  the  triangle  which  we  there  observe.  Anteriorly,  the  sac  is 
covered  by  the  origin  of  the  fibres  of  the  orbicularis,  and  a  few 
fibrous  lamellas  which  are  continuous  with  the  periostium  of  the 
root  of  the  nose.  Its  internal  surface  is  lined  by  a  mucous  mem- 
brane, which  is  usually  a  little  redder  than  that  of  the  lachrymal 


54  OF    THE    HEAD. 

As  this  sac  is  adherent  by  its  external  surface  to  solid  and 
immoveable  parts,  its  relations  are  consequently  fixed  and  un- 
changeable ;  that  is  to  say,  it  is  incapable  of  active  alternate 
dilatation  and  contraction  in  its  natural  state.  This  circumstance 
shows  us  the  futility  of  the  advice  given  by  Monro,  to  introduce 
a  sound  into  the  lachrymal  sac  through  the  nasal  duct,  for  the 
purpose  of  stretching  the  anterior  paries  of  the  former,  whilst 
cutting  into  it  in  the  operation  for  Fistula  by  the  method  of  J.  L. 
Petit.  It  is  also  on  account  of  this  intimate  adhesion  of  the  sac 
to  the  osseous  groove,  that  we  are  induced  to  give  the  following 
directions  for  penetrating  its  cavity :  We  should  direct  the  point 
of  the  bistoury  obliquely  downwards,  inwards,  and  backwards, 
below  the  direct  tendon,  and  then  in  proportion  as  we  plunge  it 
deeper,  gradually  elevate  the  handle  of  the  instrument  towards 
the  head  of  the  eye-brow.  In  this  manner  we  will  be  sure  to 
enter  into  the  sac,  and  to  incise  it  to  a  great  extent,  without 
making  but  a  small  opening  in  the  skin.  In  fact,  the  point  of 
the  instrument  having  entered  the  sac  very  high  up,  it  follows 
that,  in  passing  it  onwards,  we  will  continue  to  cut  its  external 
paries,  which  is  longer  than  the  internal,  and  that  we  will  run  no 
other  risks  than  that  of  penetrating  uselessly  to  the  bone,  by  tra- 
versing the  mucous  and  fibrous  laminae  of  the  internal  paries  of 
the  sac :  but,  on  the  one  hand,  the  compact  union  of  these 
parts  will  prevent  their  being  separated,  and,  on  the  other,  the 
instrument  will  soon  enter  the  sac  by  the  swinging  motion  which 
we  make  it  execute  ;  so  that  the  worst  which  can  happen  will  be 
reduced  to  a  simple  incision  of  these  membranes  in  a  point  which 
we  are  recommended  to  avoid ;  an  incision  which  cannot  be 
more  serious  than  the  external,  since  the  parts  divided  are  of  the 
same  nature. 

The  Nasal  Duct  is  the  continuation  of  the  preceding :  lined  by 
the  same  mucous  membrane,  it  adheres  to  the  osseous  canal 
throughout  its  whole  extent,  which  makes  it  almost  an  inert  pas- 
sage in  relation  to  the  operations  which  its  diseases  call  for ;  from 
whence  arises  the  success  obtained  from  the  use  of  the  metallic 
ranula,  so  highly  recommended  by  Pellier,  Foubert,  Wathen, 
P>.  Bell,  Dupuytren,  Taddei,  etc. 

This  duct  is  from  five  to  seven  lines  in  length :  it  is  a  little 
broader  than  the  lachrymal  sac,  and  its  antero-posterior  diameter 


OF    THE    HEAD.  55 

is  a  little  greater  than  its  transverse.  United  to  this  sac,  and  con- 
sidered as  extending  downwards  from  the  tendon  of  the  orbicu- 
laris,  it  presents  a  slight  curvature  with  an  external  and  anterior 
convexity.  The  lachrymal  portion  alone,  on  the  contrary,  is 
slightly  convex  inwards  and  backwards.  It  is  important  to  be 
well  acquainted  with  this  disposition,  whenever  we  wish  to  pass 
Instruments,  etc.,  from  the  puncta  lachrymalia  to  the  nose,  or  to 
place  foreign  bodies  in  it.  We  will  take  up  the  consideration  of 
the  inferior  orifice  of  the  nasal  duct,  when  we  come  to  the 
nasal  fossa?. 

The  bones  which  inclose  the  nasal  canal  also  merit  some  atten- 
tion. Thus  the  lachrymal  gutter  is  hollowed  out,  anteriorly,  in 
the  posterior  border  of  the  ascending  process  of  the  os  maxil- 
lare  ;  posteriorly,  in  the  external  surface  of  the  os  unguis :  there- 
fore, when  we  wish  to  make  an  artificial  course  for  the  tears, 
according  to  the  method  of  Wolhouse  or  that  of  Scarpa,  it  is 
better  to  perforate  the  bones  in  the  latter  direction  than  in  the 
former,  because  the  os  unguis  is  much  thinner  than  the  nasal  pro- 
cess. In  this  situation  these  bones  correspond  to  the  middle 
meatus  (of  the  nasal  fossa).  The  nasal  canal  is  formed,  anteri- 
orly, by  the  prolongation  of  the  lachrymal  gutter  of  the  ascending 
process,  and  on  this  side,  does  not  correspond  to  any  important 
organ ;  posteriorly,  by  the  inferior  portion  of  the  os  unguis  and 
its  curved  crest,  by  some  lamella  of  the  superior  maxillary  and 
a  small  portion  of  the  inferior  turbinated  bone.  This  wall  is  thin 
and  very  brittle,  so  that  nothing  would  be  more  easy,  in  opera- 
ting for  fistula  lachrymalis,  etc.  than  to  penetrate  into  the  nasal 
fossae  or  maxillary  sinus,  if  the  instrument  is  directed  too  far 
backwards.  The  internal  wall  of  this  canal  is  formed  by  the 
prolongation  of  the  os  unguis,  and  the  curved  portion  of  the  infe- 
rior turbinated  bone.  It  is  not  more  solid  than  the  preceding, 
and  as  it  corresponds  directly  to  the  nostril,  it  may  be  depressed 
by  polypi  or  other  tumours  which  are  developed  in  the  nose  : 
whence  epiphora,  fistula  lachrymalis,  etc. ;  finally,  its  external 
wall  is  constituted  by  the  lamina  which  borders  the  maxillary 
sinus,  and  sometimes  a  small  process  of  the  inferior  maxillary 
bone  which  is  joined  with  it.  It  is  as  thin  as  any  of  the  others, 
and  very  much  exposed  to  fractures,  or  perforations,  in  probing 
the  canal  as  recommended  by  Laforcst.  We  then  penetrate  the 


50  OF   THE   HEAD. 

maxillary  sinus.  For  the  same  reason,  tumours  of  this  last  cavity 
seldom  acquire  a  certain  volume  without  impeding  and  even  pre- 
venting the  descent  of  the  tears  into  the  inferior  meatus  (of  the 
nasal  fossa?). 

Between  the  lachrymal  sac  and  the  globe  of  the  eye,  on  the 
one  part,  the  palpebral  commissure  and  the  puncta  lachryma- 
lia,  on  the  other,  we  find  the  caruncula  lachrymalis.  This  small 
organ  is  pale  when  serous  effusions  exist  in  the  large  cavities  of 
the  body,  and  of  a  more  or  less  reddish  white  in  the  normal 
state.  It  is  formed  by  a  fold  of  the  conjunctiva,  in  which  a  con- 
siderable number  of  agglomerated  follicles,  hairs  and  even  a  small 
cartilage  are  found.  To  these  may  be  added  the  lachrymal 
muscle,  which  is  situated  behind  the  sac  and  canals  of  the  same 
name,  to  which  it  adheres,  and  which  it  may  compress  and  even 
draw  towards  the  os  unguis,  which  is  its  fixed  point.  These  uses, 
recently  attributed  to  this  small  muscle  by  Homer  and  Gery. 
appear  to  be  real,  notwithstanding  Trasmondi  has  affirmed  the 
contrary.  They  enable  us  to  understand  how  a  spasmodic  con- 
traction may  take  place  in  the  lachrymal  organs  in  one  point, 
whilst  it  does  not  appear  possible  for  this  phenomenon  to  mani- 
fest itself  in  the  nasal  canal,  properly  so  called.  Furthermore, 
the  caruncula  lachrymalis  actually  possesses  all  the  elements  of 
a  complete  eyelid,  and  thus  presents  us  with  the  rudiment  of  the 
membrana  nictitans  of  birds,  &c. 

It  is  by  the  internal  extremity  of  the  groove  which  separates 
the  caruncle  from  the  inferior  eyelid,  that  Pouteau  advised  pene- 
trating into  the  lachrymal  sac ;  and  more  recently  it  has  been 
proposed  to  penetrate  it  by  commencing  the  incision  in  the  groove 
which  separates  this  caruncle  from  the  superior  palpebra,  in  order 
to  incise  it  to  a  much  greater  extent :  in  the  latter  case,  however, 
the  muscle  of  Horner  would  be  cut  across,  and  if  it  is  true,  that 
its  action  is  useful  for  the  excretion  of  the  tears,  we  conceive 
that  considerable  inconvenience  would  result  from  it. 

S.  The  Orbitary  Portion  properly  so  called. 

The  globe  of  the  eye  occupies  the  centre  of  it,  and  is  more 
nearly  approximated  to  the  anterior  than  the  posterior  plane. 
The  form  of  this  organ  is  that  of  a  spheroid  slightly  flattened 


OF    THE    HEAD,  57 

upon  four  surfaces.  Its  antero-posterior  diameter  is  about  ten  or 
twelve  lines ;  in  the  other  directions  it  presents  a  line  less. 

It  is  from  these  dimensions  of  the  interior  of  the  eye  that  Hey 
advises  a  needle  of  only  seven  or  eight  lines  long  for  the  depres- 
sion of  the  crystalline,  and  for  the  same  reason  Groefe  has  added 
a  species  of  shoulder  to  the  shaft  of  his,  for  the  operation  of 
Keratonyxis. 

The  eye  is  divided  into  two  chambers,  the  anterior  and  poste- 
rior. The  anterior  is  bounded  by  the  iris  behind  and  by  the  cor- 
nea before  ;  its  transverse  diameter  is  from  four  to  five  lines,  its 
perpendicular  diameter  a  little  (quelques  millimetres)  less.  From 
the  pupil  to  the  centre  of  the  cornea  the  distance  is  about  two 
lines.  This  space  then  gradually  diminishes  in  proportion  as  we 
approximate  the  great  circumference  of  the  iris,  where  this  mem- 
brane touches  the  cornea ;  from  which  circumstance,  when  we 
perform  the  keratonyxis,  the  concavity  of  the  needle  must  look 
forwards,  whilst  we  penetrate  into  the  anterior  chamber.  In  fact, 
if  the  point  of  this  instrument  was  directed  backwards,  or  if  we 
made  use  of  straight  needles,  like  those  of  Beers,  Schmidt,  Him- 
ly,  &c.,  it  would  be  difficult  to  arrive  at  the  pupil  without  wound- 
ing the  iris. 

The  transparent  cornea,  which  entirely  belongs  to  this  cham- 
ber, forms  nearly  the  anterior  'fifth  part  of  the  eye  ;  its  circum- 
ference is,  as  it  were,  cased  in  the  anterior  aperture  of  the  scle- 
rotica,  and  as  it  is  the  segment  of  a  smaller  circle  than  the  rest 
of  the  organ,  it  forms  a  kind  of  superficial  furrow  upon  the  ex- 
ternal surface  of  the  membranes,  near  the  point  where  this  sur- 
face corresponds  to  the  iris.  This  groove  prevents  us  from  inclin- 
ing the  handle  of  the  knife  so  much  forwards,  in  the  extraction  of 
the  cataract,  as  the  perpendicular  of  the  eye  would  seem  to  require. 

This  membrane  is  composed  of  six  slightly  extensible  and  brit- 
tle laminae,  separated  by  an  albuminous  fluid,  which,  on  concre- 
ting, during  inflammations  of  the  eye,  produces  opacity  of  the 
cornea.  It  is  between  these  laminae  that  the  ceratotome  slides, 
in  traversing  the  cornea,  in  order  to  enter  the  anterior  chamber, 
when  the  surgeon  does  not  follow  exactly  the  perpendicular  of 
the  furrow  mentioned  above.  Anteriorly,  it  is  covered  by  a  la- 
mella which  seems  to  appertain  to  the  conjunctiva,  but  which 
only  assumes  the  characters  of  mucous  membranes  in  certain 

8 


58 


OF    THE    HEAD. 


diseases.  This  lamella  is  so  intimately  adherent  to  the  horny 
tissue,  that  it  is  scarcely  possible  to  separate  them  by  dissection : 
which  has  led  several  anatomists*  to  suppose  that  its  nature  was 
different  from  that  of  the  conjunctiva.  Be  this  as  it  may,  it  is 
between  it  and  the  transparent  membrane  of  the  eye  that  the 
serosity  accumulates  which  constitutes  the  phlyctenae  of  the 
cornea. 

Posteriorly,  it   is  lined  by  the  membrane  of  the  aqueous  hu- 
mour, a  species  of  lamina  which  does  not  appear  to  cover  the  fore 
part  of  the  iris,  notwithstanding  several  very  correct  observers  say 
that  it  does  so.     The  anterior  chamber  is  filled  with  a  liquid 
which  is  reproduced  with  great  facility,  in  young  subjects  espe- 
cially.    It  is  on  account  of  the  presence  of  this  fluid  that,  when 
the  cornea  is  once  traversed,  the  instrument  must  never  be  with- 
drawn ;  because,  no  longer  filling  exactly  the  opening  which  it 
has  made,  the  water  will  escape  from  the  cavity  which  encloses 
it,  and  the  eye  becoming  flaccid,  the  section  must  necessarily  be 
completed  with  the  scissars.     As  the  tranverse  diameter  of  the 
cornea  is  the  greatest,  we  prefer,  in  the  operation  for  cataract, 
the  incision  from  the  temporal  angle  towards  the  nose,  to  the  ver- 
tical incision.     Wenzel   and   the  greater  proportion  of  French 
surgeons  advise  us  to  traverse  the  anterior  chamber,  not  directly 
across,  as  recommended  by  La  Faye,  but  very  obliquely  from 
above  downwards  and  from  without  inwards,  for  fear  that  the 
flap  might  be  raised  by  the  depression  of  the  eye,  or  by  the  move- 
ments of  the  lower  lid.     This  method  of  operating  does  not  ap- 
pear to  us  to  be  free  from  censure,  or,  at  least,  is  not  so  essential  as 
many  authors  pretend.     In  fact,  in  attempting  to  traverse  the  eye 
in  this  direction,  the  prominence  of  the  external  orbitary  process 
of  the  os  frontis  will  sometimes  throw  the  handle  of  the  knife  so 
far  forwards,  that  it  will  be  difficult  to  make  its  point  pass  out  in 
the  great  angle,  without  wounding  parts  which  it  is  of  importance 
to  avoid  ;  besides  the  anatomical  disposition  of  the  parts  does  not 
permit  the  flap  of  the  cornea  to  be  readily  raised  by  the  free  bor- 
der of  the  lower  lid,  and  further,  after  the  operation,  the  patient 
has  his  eyes  closed  :  it  is  the  superior  palpebra  which  descends, 
and  not  the   inferior  that  rises.     Neither  would  the  eye  itself, 
when  descending,  favour  the  occurrence  of  this  accident ;  and  if, 

*  M,  Ribes. 


OP   THE    HEAD.  59 

moreover,  it  should  happen,  it  is  not  the  oblique  incision  which 
would  prevent  it,  for  the  internal  extremity  of  the  flap  would  be 
equally  exposed  to  the  same  eversion.  In  short,  we  think  that  this 
question  requires  further  examination. 

The  posterior  chamber  is  extremely  complicated.  Its  walls 
are  formed  by  three  membranes  placed  one  within  the  other, 
and  are  thus  arranged :  the  sclerotic,  external ;  the  choroid,  cen- 
tral ;  and  the  retina,  internal. 

The  first  is  thickest  posteriorly,  but  is  strengthened  anteriorly 
by  the  fibrous  expansion  of  the  muscles  ;  it  is  composed  of  paral- 
lel fibres,  which  extend  from  the  optic  nerve  towards  the  cornea ; 
some  also  are  circular  and  transverse,  but  these  last  are  less 
numerous. 

The  second,  or  choroid  is  essentially  formed  by  vessels.  On 
its  external  surface,  between  it  and  the  sclerotic,  the  ciliary  nerves 
are  observed.  When  it  reaches  the  ciliary  circle  it  curves  be- 
hind the  iris  in  order  to  form  the  uvea,  and  it  is  at  the  place  of  this 
curvature  that  it  gives  rise,  in  folding  upon  itself,  to  the  ciliary 
processes,  which  are  separated  from  the  great  circumference  of 
the  iris  by  the  commissure  of  the  choroid,  upon  the  posterior  sur- 
face of  which  they  are  supported. 

The  third,  or  retina,  white,  pulpy,  in  which  the  nervous  matter 
of  the  optic  nerve  is  met  with,  appears  to  be  the  essential  organ  of 
vision.  It  is  situated  between  the  choroid  and  the  vitreous  body, 
and  is  prolonged  at  least  to  the  circumference  of  the  crystalline 
lens.  We  have  several  times  distinctly  observed  it,  in  man,  ex- 
tend to  the  iris ;  and  in  the  bullock  it  is  much  more  readily  distin- 
guished. Is  this  a  natural  state,  or  is  it  merely  an  anomaly  ? 

These  three  membranes  are  traversed  by  the  needle  in  the 
operation  for  cataract.  As  the  fibres  of  the  external  are  parallel 
to  the  axis  of  the  eye,  and  as  the  central  is  composed  of  vessels 
and  nerves  which  follow  the  same  direction,  it  is  necessary  to  in- 
troduce the  needle  in  such  a  manner  that  one  of  its  edges  looks 
forwards,  the  other  backwards,  its  concavity  being  turned  down- 
wards. By  acting  in  this  way  we  only  separate,  if  I  may  so  say, 
the  fibres  and  the  vessels.  On  the  contrary,  if  the  needle  is  so 
held  that  its  concavity  is  directed  backwards  and  its  cutting 
edges  perpendicular  to  the  axis  of  the  eye,  it  will  necessarily 
divide  the  parts  through  which  it  passes,  and  thereby  give  rise  to 


GO  OF    THE    HEAI1. 

ecchymoses  between  the  conjunctiva  and  scierotica,  to  extra- 
vasation of  blood  within  the  posterior  chamber,  or  to  nervous 
symptoms,  on  account  of  the  lesion  of  the  ciliary  arteries  or 
nerves. 

The  posterior  chamber  is  filled  by  a  globular  body  composed 
of  the  vitreous  body  and  crystalline.  The  latter  is  a  species  of 
inert  and  transparent  lens,  which  is  always  more  solid  at  the  cen- 
tre than  at  the  periphery ;  whence  it  follows  that  its  opacity  is 
generally  eccentric.  The  crystalline  capsule,  which  envelopes 
it,  is  separated  from  it  by  a  space  which  is  usually  in  a  direct  ra- 
tio to  the  age :  this  space  is  naturally  filled  by  an  albuminous 
liquid,  susceptible  of  losing  its  transparency  by  passing  into  a 
milky  or  purulent  state ;  which  constitutes  the  cataracts  thus 
named.  The  capsule  itself  is  enveloped  in  a  separation  of  the 
membrana  hyaloidea,  so  that  posteriorly  it  rests  upon  the  anterior 
part  of  the  vitreous  humour,  the  tunic  of  which  sends  a  lamina 
upon  the  fore  part  of  that  of  the  crystalline.  This  capsule  ap- 
pears to  be  of  a  horny  nature  ;  it  is  dense,  elastic  and  resists  the 
entrance  of  the  instrument :  a  circumstance  not  to  be  forgotten 
when  we  attempt  the  depression  of  the  cataract.  Some  have 
thought  that  its  internal  surface  secretes  the  lens  itself,  and  that 
this  body  may  be  regenerated  after  its  depression  or  extraction, 
provided  the  capsule  is  not  at  the  same  time  destroyed.  Doctor 
Cocteau  has  recently  presented  to  the  Royal  Academy  of  Medi- 
cine the  result  of  his  experiments  upon  dogs  and  rabbits,  which 
seem  to  give  support  to  this  opinion.  Prof.  Beclard  was  deputed 
to  resolve  this  important  question,  and  had  already  extracted  the 
crystalline  from  the  eye  of  several  dogs,  when  death  snatched  him 
away  in  the  midst  of  his  useful  labours.  If  the  assertion  of  M . 
Cocteau  is  confirmed,  it  will  be  necessary,  in  every  operation  for 
cataract,  to  extract  even  the  minutest  particles  of  the  crystalline, 
unless  we  take  care  to  destroy  the  formative  organ,  that  is  to  say 
the  capsule  itself. 

The  vitreous  body  is  a  species  of  sponge  with  very  fine  and 
transparent  meshes ;  it  is  formed  by  a  substance  similar  to  the 
aqueous  humour  and  by  a  membrane,  the  laminae  of  which  split 
and  intersect  each  other  a  great  many  times,  forming  the  cellules 
which  enclose  the  fluid.  This  membrane,  according  to  Mr.  J.  Clo- 
quet,  is  reflected  upon  itself  behind,  in  order  to  form  the  hyaloid 


OP   THE    HEAD.  61 

canal,  which  passes  through  the  entire  thickness  of  the  vitreous 
body,  conveying  an  artery  to  the  crystalline  capsule.  On  the 
other  hand,  according  to  Petit,  the  learned  anatomist  whom  we 
have  just  cited,  when  the  hyaloid  membrane  arrives  near  the  cir- 
cumference of  the  crystalline  and  its  capsule  it  separates  into  two 
laminae,  between  which  laminae  the  visual  lens  is  found ;  so  that, 
if  we  consider  the  crystalline  as  removed,  the  vitreous  humour 
would  bear  a  resemblance  to  the  larger  end  of  an  egg,  and  the 
vacancy  which  habitually  exists  between  the  membrane  retracted 
by  the  albumen  and  the  calcareous  shell. 

In  couching,  the  vitreous  body  is  always  perforated,  use  what 
precautions  we  may  ;  and  we  think,  that,  far  from  seeking  to  avoid 
this,  we  should  always  endeavour  to  open  it  sufficiently  for  the 
purpose  of  imbedding  the  lens  within  it ;  and  in  order  to  do  this, 
the  needle  having  entered  the  posterior  chamber,  one  of  its  cut- 
ting edges  should  be  carried  backwards  and  downwards,  below 
the  visual  axis,  dividing  several  of  the  laminae  of  the  hyaloid  in 
this  direction,  so  that  we  may  be  enabled  to  push  the  opaque  body 
into  it,  after  having  placed  the  instrument  upon  the  fore  part  of  its 
capsule.  In  this  way,  the  elasticity  of  the  vitreous  body  will  not 
oppose  the  entrance  of  the  crystalline  into  it,  but  will  rather  re- 
tain it  in  the  situation  in  which  we  leave  it.  On  the  contrary,  if 
we  depress  it  between  the  membrana  hyaloidea  and  retina,  we 
will  necessarily  disorganize  the  latter,  and  that  elasticity,  which, 
in  the  first  case,  retained,  will  constantly  tend  to  press  it  upward. 
We  do  not  see  what  danger  can  follow  this  method,  which  is 
moreover  frequently  adopted  without  anticipating  any.  Our  for- 
mer preceptor  and  friend,  Dr.  Bretonneau,  always  operates  in 
this  manner,  and  his  success  establishes  this  precept.  The  meth- 
od by  hycdonixis,  recently  recommended  by  M.  Bowen,  and  for- 
merly detailed  by  Farrein  to  the  Academy  of  Sciences,  clearly 
proves  that  we  have  nothing  to  apprehend  from  the  lesion  of  the 
vitreous  body. 

Considered  posteriorly,  the  posterior  chamber  of  the  eye  forms 
the  bottom  of  this  organ,  and  upon  it  the  image  of  objects  is 
painted.  We  there  find  the  posterior  opening  of  the  hyaloid  ca- 
nal, and  the  artery  or  pedicle  which  attaches  the  vitreous  body  to 
the  retina  ;  the  retina  itself,  with  its  folds  and  its  punctum  flavum, 
which  are  about  two  lines  on  the  outer  side  of  the  optic  nerve, 


VZ  OF    THE    HEAD. 

that  is  to  say,  nearly  in  the  direction  of  the  axis  of  the  eye  ;  the 
choroid,  which  is  perforated  for  the  entrance  of  the  optic  nerve  ; 
finally,  the  sclerotica,  which  is  likewise  pierced  by  the  same  nerve, 
which  furnishes  it  with  a  fibrous  expansion  coming  from  the  dura 
mater,  and  which  is  situated  about  two  lines  on  the  inner  side  of 
the  visual  axis  in  man. 

Anteriorly,  the  posterior  chamber  is  separated  from  the  anterior 
by  the  iris,  a  membrane  placed  vertically,  with  a  central  opening, 
which  constitutes  the  pupil.  This  organ  is  of  a  very  complicated 
texture,  and  seems  to  contain,  according  to  some  anatomists,  a 
prolongation  of  the  retina,  of  the  choroid,  of  the  membrane  of 
the  aqueous  humour,  and  a  cellulo-vascular  lamina  propria.  Ac- 
cording to  others,  it  is  essentially  formed  by  the  long  ciliary  arte- 
ries, which  anastomose  four  or  five  times  in  a  circular  direction. 
Some  say  that  it  is  an  erectile  (spongy)  tissue ;  others,  a  double 
muscle.  Be  this  as  it  may,  in  certain  subjects  it  bulges  forwards  a 
little,  in  children  especially,  and  is  thereby  exposed  to  the  knife  as 
it  crosses  the  anterior  chamber.  This  is  most  liable  to  happen 
when  the  aqueous  humour  has  escaped. 

Its  posterior  surface,  slightly  concave,  is  black ;  we  call  it  uvea. 
It  is  separated  from  the  capsule  of  the  lens  by  an  interval  of  half 
a  line,  which  is  filled  by  the  aqueous  humour.  The  narrowness 
of  this  space  renders  it  at  least  very  difficult  to  pass  a  needle  be- 
fore the  crystalline  without  perforating  the  vitreous  body ;  espe- 
cially, as,  if  we  admit  that  the  posterior  chamber  is  bounded  be- 
hind by  the  anterior  surface  of  the  vitreous  body,  the  crystalline 
lens  being  removed,  we  would  have  the  same  disposition  behind 
the  iris  as  before  it ;  that  is  to  say,  that  the  hyaloid  membrane,  like 
the  cornea,  is  at  first  from  two  to  three  lines  distant  from  the  pu- 
pil, but  afterwards  approximates  so  close  to  the  great  circumfer- 
ence of  the  iris,  that  it  appears  to  be  in  direct  contact  with  the 
ciliary  processes.  Is  it  not  evident,  then,  according  to  this  dis- 
position which  does  not  vary,  that,  in  passing  the  instrument 
from  the  sclerotica  to  the  pupil,  whether  by  the  ordinary  method, 
or  that  of  M.  Bo  wen,  we  will  divide  the  vitreous  body  more  or 
less  extensively  ? 

The  great  circumference  of  the  iris  being  attached  to  the  union 
of  the  cornea  with  the  sclerotica,  before  the  ciliary  circle  (liga- 
mentum  ciliare),  and  there  receiving  the  principal  vessels  which 


OF    THE    HEAD.  03 

enter  into  its  composition,  it  follows,  that,  in  making  an  artificial 
pupil,  according  to  the  recommendation  of  Scarpa,  we  are  in  dan- 
ger of  lacerating  the  nervous  ring,  and  of  producing  considerable 
haemorrhage.  It  must  be  admitted,  however,  that  it  is  possible  to 
avoid  these  accidents. 

By  taking  the  precaution  of  introducing  the  needle  at  a  suffi- 
cient distance  from  the  triple  union  of  the  iris,  ciliary  body  and 
cornea,  there  would  also  be  an  advantage  in  it  relative  to  the  lat- 
ter membrane,  which,  being  more  remote  from  the  retractile  veil 
of  the  eye,  would  run  less  risk  of  being  caught  by  the  point  of 
the  instrument.  We  have  witnessed  the  occurrence  of  this  acci- 
dent in  a  patient  operated  upon  by  one  of  the  most  celebrated 
surgeons  in  Paris. 

The  small  circumference  of  the  iris  is,  as  we  know,  susceptible 
of  alternate  dilatation  and  contraction,  which  every  body  explains 
according  to  his  own  notion,  or  rather  does  not  explain  at  all.  It 
is  in  passing  before  this  opening,  that  is  to  say,  before  the  pupil, 
that  Wenzel  dips  the  point  of  his  knife  into  the  posterior  cham- 
ber and  divides  the  capsule  of  the  crystalline,  at  the  same  time 
that  he  crosses  the  anterior  chamber  in  order  to  form  a  flap  of  the 
cornea.  It  is  also  by  this  opening  that  the  diverse  kystitomes  fulfil 
the  same  indication,  and  that  we  arrive  at  the  lens  in  the  kerato- 
nyxis,  etc. ;  to  facilitate  which  it  is  useful  to  dilate  it  by  means  of 
the  solution  of  the  extract  of  Belladonna,  or  any  other  substance 
possessing  analogous  properties.  This  dilatation  is  also  necessary 
in  order  to  prevent  the  iris  from  being  pricked  by  the  instrument, 
especially  when  couching.  In  fact,  Beclard  was  convinced  that 
most  of  the  accidents  which  sometimes  follow  the  depression,  are 
owing  to  the  tractions  of  the  iris,  and  that,  according  to  his  expe- 
rience, if  care  was  taken  to  avoid  touching  this  membrane,  couch- 
ing would,  without  contradiction,  be  preferable  to  extraction. 
Would  not  this  idea  be  in  favour  of  those  who  admit  of  a  lamina 
of  the  retina  behind  the  iris  ? 

The  vessels  of  the  ocular  globe  are  exceedingly  numerous  and 
delicate.  Anteriorly,  this  organ  receives  branches  from  the  pal- 
pebral  and  anterior  ciliary  arteries,  which  are  distributed  to  the 
conjunctiva,  and  are  rendered  equally  visible  upon  the  cornea  by 
inflammation  ;  posteriorly,  it  receives  the  arteria  centralis  retinae, 
which  accompanies  the  optic  nerve.  After  having  given  off 


64  OF   THE    HEAD. 

many  ramuscules  to  the  nervous  membrane  of  the  eye,  this  ves- 
sel, according  to  authors  who  call  it  the  central  artery  of  the 
crystalline,  passes  through  the  canalis  hyaloidea  to  the  posterior 
lamina  of  the  membrane  of  the  lens.  We  have  never  seen  it 
penetrate  into  the  lens  itself.  This  artery  should  be  preserved 
during  depression,  for  it  is  probable  that  its  laceration  would  be 
detrimental  to  vision.  The  ciliary  arteries  form  in  the  eye  a  very 
complicated  net-work ;  all  of  them  perforate  the  sclerotica  ob- 
liquely, principally  in  its  posterior  third  portion ;  their  numerous 
filaments  afterwards  place  themselves  in  the  choroid  and  run  in 
parallel  lines  to  the  ciliary  processes  and  uvea,  with  the  excep- 
tion, however,  of  the  two  long  ciliary  arteries,  which  run  along 
the  internal  surface  of  the  sclerotica,  and  do  not  divide  until  they 
reach  the  great  circumference  of  the  iris.  It  is  in  consequence 
of  the  position  of  these  two  branches  upon  the  two  extremities 
of  the  transverse  diameter  of  the  eye,  that  we  are  advised  to 
introduce  the  needle  below  it,  in  the  operation  of  couching  ;  and 
it  is  also  on  account  of  their  size  and  direction,  that  we  consider 
it  best  to  turn  the  edges  of  the  instrument  anteriorly  and  poste- 
riorly, as  we  have  previously  mentioned. 

The  greater  proportion  of  the  veins,  also,  are  situated  in  the 
choroid.  We  find,  besides,  between  this  tunic  and  the  vitreous 
body,  the  vortices  of  Haller,  or  the  vasa  vorticosa.  These  ves- 
sels pass  through  the  fibrous  membrane  and  empty  their  blood 
into  the  lachrymal  veins. 

The  nerves  are  derived  from  the  ophthalmic  ganglion :  they 
are  distributed  in  the  same  manner  and  follow  the  same  direction 
as  the  arteries,  and  are  lost  in  the  ciliary  circle.  This  ring,  which 
has  all  the  characters  of  a  circular  nervous  ganglion,  would,  in 
this  case,  appertain  to  the  great  sympathetic :  its  figure  is  pris- 
matic, and  its  external  side  rests  upon  the  most  anterior  part  of 
the  internal  surface  of  the  sclerotica.  Anteriorly,  it  separates  the 
iris  from  the  choroid  or  ciliary  processes,  to  which  it  adheres 
posteriorly.  This  point  of  the  envelope  of  the  eye  is  worthy  of 
attention.  It  is,  in  fact,  with  the  view  of  avoiding  the  iris,  that 
we  are  advised,  in  extracting  the  cataract,  to  penetrate  the  ante- 
rior chamber  half  a  line  before  the  sclerotica.  In  depression,  if 
we  introduced  the  needle  at  less  than  a  line  and  a  half  behind  it, 
we  would  inevitably  wound  either  the  great  arterial  circle  of  the 


OF   THE    HEAD.  65 

iri.s,  the  ganglion  (ciliary  ligament),  or  the  ciliary  processes. 
Now,  if  it  was  certain  that  we  would  not  more  surely  avoid  the 
retina  or  vitreous  body  by  introducing  the  needle  at  this  point 
than  more  posteriorly,  it  seems  to  us  that  it  would  still  be  pref- 
erable to  approximate  these  parts  as  little  as  possible. 

The  nerves  of  the  interior  of  the  eye  may  be  distributed  in 
three  orders. 

The  first  are  destined  for  the  movements  of  the  iris,  and  are 
derived  from  the  nasal  branch  of  the  ophthalmic  and  the  lachry- 
mal only  ;  whence  it  follows,  that  wounds  inflicted  upon  the 
angles  of  the  eye  sometimes  suspend  the  contractions  of  the  iris 
without  interrupting  vision.  Baron  Larrey,  with  whom  this  idea 
appears  to  have  originated,  has  met  -with  several  cases  of  this 
nature ;  and  but  a  short  time  since,  there  was  a  case  of  the  kind 
at  the  Societe  Philomatique ;  so  that  we  have  been  able  to  con- 
vince ourselves  of  the  correctness  of  the  fact.  The  second 
order  includes  the  nerve  of  special  sensation,  which  does  not, 
according  to  the  celebrated  Magendie,  enjoy  general  sensibility, 
but  is  destined  solely  to  receive  the  impression  of  images  :  it  is 
the  optic  nerve.  Its  anatomical  disposition  explains  to  us  why 
paralysis  of  the  retina  does  not  alter  the  state  of  the  other  parts 
of  the  eye,  or  necessarily  induce  immobility  of  the  iris.  Finally, 
the  nerves  of  the  third  order  appertain  to  the  interior  life  and 
enter  into  the  ganglionic  system :  these  are  the  numerous  ciliary 
filaments  and  ciliary  circle. 

The  order  in  which  the  parts  of  the  eye  present  themselves,  in 
proceeding  from  the  anterior  to  the  posterior  part  of  this  organ, 
is  the  following:  1st,  the  conjunctiva,  or  the  lamina,  whatsoever 
it  may  be,  which  covers  the  cornea  ;  2d,  the  transparent  cornea  ; 
3d,  the  membrane  of  the  aqueous  humour;  4th,  the  anterior 
chamber,  which  is  two  lines  in  diameter  in  the  direction  of  the 
ocular  axis  ;  5th,  the  aqueous  humour,  which  is  regenerated  with 
great  facility ;  6th,  the  iris,  the  pupil,  or  membrana  pupillaris  in 
the  foetus  under  seven  months  ;  7th,  the  space  which  separates 
the  iris  from  the  crystalline,  a  space  which  scarcely  exists  in  chil- 
dren, which  does  not  exceed  half  a  line  in  the  adult,  and  which 
many  consider  as  the  posterior  chamber,  properly  so  called :  it  is 
also  filled  with  the  aqueous  humour :  8th,  the  anterior  portion  of 
the  capsule  of  the  Ions,  covered  by  a  lamina  of  the  hyaloid  ;  9th, 

9 


66  OF    THE    HEAD. 

a  small  space  which  separates  the  anterior  surface  of  tbe  crystal- 
line  from  its  capsule,  and  which  is  filled  by  the  Liquor  Morgagni ; 
10th,  the  crystalline  lens,  softer  and  more  spherical  in  children 
than  in  old  people,  whence  it  follows  that  myopia  is  more  fre- 
quent in  the  former  and  presbyopia  in  the  latter  ;  llth,  between 
the  posterior  surface  of  this  body  and  its  capsule,  another  space, 
filled  with  a  liquid  similar  to  that  w^hich  is  anterior  to  it ;  12th, 
the  posterior  lamina  of  the  capsule  of  the  lens,  thicker  and  more 
dense  than  the  anterior,  invested  posteriorly  by  the  membrana 
hyaloidea ;  13th,  the  vitreous  body,  the  canalis  hyaloidea,  and 
the  central  artery  of  the  crystalline  lens;  14th,  the  retina  formed 
of  three  laminae,  according  to  some  authors ;  15th,  the  choroid, 
bifoliated  according  to  Ruysch,  etc.;  16th,  the  sclerotic. 

In  penetrating  transversely  into  the  posterior  chamber  of  the 
eye,  we  find  from  without  inwards,  1st.  the  sclerotica ;  2d.  the 
choroid ;  3d.  the  retina ;  4th.  the  hyaloid  membrane ;  5th.  the 
vitreous  body ;  6th.  the  hyaloid  canal,  the  central  artery  of  the 
crystalline,  or,  more  anteriorly,  the  lens  itself  and  its  capsule. 
With  respect  to  the  anterior  chamber,  1st.  the  conjunctiva ;  2d. 
the  cornea ;  3d.  the  membrane  of  the  aqueous  humour ;  4th.  the 
aqueous  humour ;  then  the  same  parts  on  the  other  side  of  the  axis. 

The  parts  which  surround  the  ocular  globe  within  the  orbit  are, 

1st.  The  muscles,  which  are,  in  the  first  place,  the  four  recti, 
the  fibrous  expansion  of  which  terminates  upon  that  portion  of 
the  sclerotica  which  is  covered  by  the  conjunctiva,  constituting 
what  is  called  the  white  of  the  eye.  Departing  from  thence, 
these  muscles  converge  so  as  to  form  a  cone,  the  apex  of  which 
surrounds  the  optic  nerve,  and  is  attached  to  the  bottom  of  the 
orbit.  From  this  disposition,  when  these  muscles  contract  to- 
gether, they  tend  to  flatten  the  eye  in  four  opposite  directions, 
and  also  to  draw  it  backwards. 

Next  the  levator  palpebrae  superioris,  which  is  situated  between 
the  rectus  superior  arid  the  periosteum ;  in  thin  persons,  or  those 
who  have  a  prominent  eye-brow,  it  is  this  muscle  which  draws 
the  eye-lid  backwards,  and  makes  it  appear  depressed. 

The  great  oblique  (trochlearis)  is  situated  between  the  rectus 
interims,  rectus  superior,  levator  and  periosteum,  as  far  as  its 
reflected  pulley,  three  lines  within  the  supra-orbital  notch,  and 
then  passes  behind  the  conjunctiva,  between  the  levator,  rec- 


OF   THE    HEAD.  t>  t 

tus  superior  and  rectus  externus,  to  be  inserted  into  the  sclero- 
tica,  three  lines  anterior  to  the  optic  nerve.  It  is  necessary  to 
remark  that  the  superficial  situation  of  this  muscle,  at  its  point  of 
reflexion,  exposes  it  to  wounds  of  different  species :  for  example, 
it  might  be  divided  when  attempting  to  divide  the  supra-orbital 
nerve,  if  we  endeavoured  at  the  same  time  to  cut  the  internal 
frontal  branch.  Such  an\accident  would  be  attended  with  loss 
of  rotation  inwards. 

The  small  (external)  oblique  is  attached  to  the  floor  of  the  orbit 
quite  near  its  circumference,  two  lines  on  the  outer  side  of  the 
superior  orifice  of  the  nasal  canal.  From  this  point  it  passes  be- 
hind the  conjunctiva  obliquely  upwards,  backwards  and  outwards? 
between  the  periosteum,  the  rectus  inferior  and  rectus  externus, 
upon  the  sclerotica.  In  consequence  of  its  slender  size  at  its 
origin,  and  its  situation,  it  is  liable  to  be  divided  in  the  operation 
for  fistula  lachrymalis,  especially  if  the  knife  should  slip  outside 
of  the  sac :  such  an  occurrence  would  destroy  rotation  outwards. 

The  direction  of  these  last  two  muscles  is  such  that,  when  they 
act  conjointly,  they  are  antagonists  to  the  recti  muscles,  drawing  the 
eye  forwards. 

2nd.  The  nerves,  which  are,  in  the  centre,  the  optic  nerve, 
enveloped  posteriorly  by  the  origin  of  the  recti  muscles,  from  the 
bellies  of  which  it  is  separated  by  a  considerable  quantity  of  fat, 
which  prevents  its  compression :  around  it,  the  superior  and  infe- 
rior ciliary  nerves  coming  from  the  ophthalmic  ganglion,  resting 
upon  the  external  surface  of  the  optic  nerve,  a  little  anterior  to  the 
attachment  of  the  muscles ;  the  third  pair  (moteur  commun),  which 
enters  the  orbitt  hrough  the  foramen  lacerum  (sphenoidal  fissure), 
crossing  the  posterior  extremity  of  the  rectus  externus  muscle  : 
the  superior  branch  of  this  nerve  is  lost  in  the  rectus  superior  and 
levator  palpebrae ;  the  inferior  gives  off  a  large  twig  to  the  rectus 
inferior,  another  to  the  obliquus  externus,  a  third  which  passes 
under  the  optic  nerve  to  be  distributed  to  the  rectus  internus,  and 
lastly  a  filament  which  forms  the  inferior  root  of  the  lenticular 
ganglion.  Next  we  find  the  abductor  oculi  (moteur  externe),  or 
sixth  pair,  which  penetrates  the  orbit  through  the  same  foramen 
as  the  preceding,  and  immediately  enters  the  rectus  externus 
muscle.  All  these  branches  are  at  first  situated  on  the  outer  side 
and  around  the  optic  nerve,  and  are  afterwards  dispersed  among 


GS  OF    THE    HEAD, 

the  five  essential  rnotores  muscles  of  the  eye.  The  researches 
of  Chas.  Bell  *  induced  him  to  think  that  these  nerves  presided 
over  the  voluntary  motions  within  the  orbit.  The  fourth  pair 
(pathetici),  according  to  the  same  author,  preside  over  the  instinc- 
tive movements  of  the  trochlearis  muscle,  and  are  therefore  con- 
genial with  the  filaments  of  the  facial,  which  are  motors  of  the 
orbicularis  palpebrarum  muscle.  In  fact,  at  the  moment  of  sleep, 
as  well  as  at  the  approach  of  death,  at  the  same  time  that  the 
upper  eye-lid  falls  the  eye  is  raised  by  the  action  of  the  troch- 
learis, because  the  will  no  longer  has  power  over  the  recti 
muscles,  etc.,  which  alone  obey  its  orders.  On  the  other  hand, 
if  we  destroy  the  facial  nerve,  the  eye-lids  will  remain  open  and 
immoveable,  whereas  the  eye  continues  to  move  under  the  influ- 
ence of  the  will.  The  patient  from  whom  Beclard  extirpated 
the  parotid  gland,  presented  a  striking  example  of  this  fact  f 
It  must  be  remarked,  however,  that  in  another  patient,  who  came 
under  the  notice  of  M.  Billard,  J  the  side  of  the  face  was  para- 
lysed in  consequence  of  the  destruction  of  the  facial  nerve,  never- 
theless, the  palpebree  continued  moveable. 

Some  nerves  of  another  order  are  also  met  with  in  the  orbit : 
these  are  filaments  of  the  ophthalmic  branch  of  the  fifth  pair 
(trigeminus),  which,  according  to  modern  research,  seem  to  ap- 
pertain exclusively  to  the  sensitive  function  of  the  parts  to  which 
they  are  distributed :  from  which  circumstance,  if  the  trunk  of  the 
nerve  is  divided,  the  subject  can  no  longer  feel  the  contact  of 
bodies  applied  to  the  eye-lids,  eye,  etc.,  as  has  been  observed  in  a 
woman  by  Dr.  Crampton,  and  in  animals  by  M.  Magendie. 

The  lachrymal  branch,  before  it  is  lost  in  the  gland  of  the  same 
name  and  the  external  angle  of  the  eye-lids,  gives  off  two  smalJ 
filaments  which  pass  through  the  os  malas  in  order  to  be  distri- 
buted to  the  cheek  and  temporal  fossa,  and  also  form  with  a  brancli 
of  the  inferior  maxillary  the  superficial  temporal.  It  is  situated 
between  the  rectus  externus  and  the  periosteum. 

The  supra-orbital,  placed  upon  the  superior  surface  of  the  leva- 
tor  palpebras  muscle,  before  passing  out  of  the  orbit  anastomoses 
by  its  internal  frontal  branch  with  the  nasal.  As  the  latter  passes 

*  Philosophical  Trans,  etc.,  1823.  and  an  Exposition  of  the  natural  system  of 
the  nerves,  etc.  London  1824. 
f  Archives,  Janvier  1824.     |  Archives  November  1824. 


OP    THE    HEAD.  ) 

over  the  optic  nerve,  it  gives  off  the  superior  root  of  the  ophthalmic 
ganglion ;  it  then  approximates  the  inner  wall  of  the  orbit,  running 
between  the  trochlcaris  and  adductor  oculi,  where  it  gives  off  the 
ethmoidal  filament  and  afterwards  comes  out  at  the  great  angle. 

Finally,  the  superior  maxillary  nerve  sends  into  the  orbit  the 
infra-orbital,  which  is  at  first  half  uncovered  in  its  groove,  but 
afterwards  completely  enclosed  in  its  canal,  previous  to  its  en- 
trance into  the  fossa  canina ;  it  also  gives  off  the  orbital  filament, 
which  anastomoses  with  the  lachrymal  and  deep-seated  temporal 
branches,  and  which  follows  the  direction  of  the  spheno-maxillary 
fissure. 

3d.  The  arteries  of  the  orbit  are  derived  from  the  ophthalmic, 
and  have  nearly  the  same  distribution  as  the  nerves ;  There  are 
none  so  large  as  to  require  important  surgical  remarks.  The 
supra-orbital  only  may  be  wounded  in  fractures  of  the  vault  of  the 
orbit :  and  the  meningea  media  sometimes  sends  a  considerable 
branch  through  the  sphenoidal  fissure  which  supplies  the  place 
of  the  lachrymal.  In  the  extirpation  of  the  eye  it  is  never  neces- 
sary to  tie  these  branches ;  their  position  and  relations  with  the 
bones  enable  us  to  compress  them  readily.  As  they  are  derived 
from  the  carotids,  it  has  been  recommended  to  tie  the  latter  in 
cases  of  aneurism  within  the  orbit,  and  the  operation  has  been 
performed  by  Mr.  Travers  of  London. 

4th.  The  veins  are  larger  than  the  arteries,  which  they  generally 
accompany.  There  is  usually  one  of  larger  size  than  the  others, 
which  passes  from  the  face  to  the  Sella  Turcica,  and  forms  a  direct 
communication  between  the  angularis  and  ophthalmic  veins.  By 
this  communication  we  may  partially  account  for  the  ready  trans- 
mission of  diseases  of  the  organs  contained  within  the  orbital 
cavity  to  the  encephalon,  and  vice  versa.  By  it,  also,  we  may 
perceive  that  the  opening  of  the  facial  vein,  in  diseases  of  the  eye, 
would  produce  a  very  prompt  disgorgement,  and  probably  we 
neglect  this  resource  too  much.  All  of  these  veins  enter  into  the 
cranium  through  the  sphenoidal  fissure  (foramen  lacerum),  and 
form,  previous  to  their  termination  in  the  coronary  sinus  (sinus 
circularis  of  Haller  and  Simmering),  a  more  or  less  complicated 
plexus,  which  might  be  called  the  ophthalmic  plexus. 

5th.  The  Lymphatics.  Some  of  them  are  continuous  with 
those  of  the  face  and  proceed  to  the  base  of  the  lower  jaw ;  the 


70  OP   THE    HEAT). 

others  pass  through  the  spheno-inaxillary  fissure  into  the  paroti- 
deal  region. 

6th.  The  lachrymal  gland  is  concealed  behind  the  external  or- 
bitary  process,  and  is  so  difficult  to  remove  that,  after  the  extir- 
pation of  the  eye,  we  arc  generally  obliged  to  dissect  it  out 
separately. 

All  the  organs  which  have  just  been  enumerated  are  separated 
by  very  large  adipose  cells,  which  are  never  entirely  wanting, 
even  in  the  most  emaciated  subjects.  This  fat  is  soft,  almost 
semi-fluid,  and  forms  an  elastic  cushion,  which  favours  the  move- 
ments of  the  eye,  and  prevents  the  recti  muscles  from  drawing 
it  backwards.  Also,  in  consequence  of  the  laxity  of  the  cellular 
tissue  which  surrounds  this  organ,  inflammations  of  the  interior 
of  the  orbit  promptly  terminate  in  suppuration,  and  this  suppura- 
tion rapidly  detaches  and  disorganizes  a  multitude  of  import- 
ant parts. 

7th.  The  Periosteum  of  the  orbit  is  a  complex  fibrous  expan- 
sion, which  seems  to  originate  from  the  dura  mater.  As  it  enters 
this  cavity  it  divides  into  two  sheets,  one  of  which  embraces  the 
optic  nerve,  and  is  confounded  with  the  sclerotica ;  the  other 
lines  the  bones,  is  reflected  upon  them  at  the  base  of  the  orbit, 
and  seems  to  produce  the  palpebral  ligament,  on  the  one  hand, 
and  to  blend  itself  with  the  periosteum  of  the  forehead,  on  the 
other. 

8th.  Lastly,  the  bones,  which  are  numerous,  and  several  of 
them  present  some  striking  peculiarities.  The  superior  paries, 
or  vault,  is  formed  by  the  orbital  portion  of  the  os  frontis,  except 
in  its  posterior  tenth,  where  we  find  the  small  ala  of  the  sphe- 
noid, which  is  perforated  obliquely  forwards  and  outwards  by 
the  optic  foramen.  Through  this  hole  the  optic  nerve  and 
artery  pass ;  above  it,  between  the  laminae  of  the  periosteum, 
the  superior  rectus  and  levator  muscles  originate,  one  above  the 
other ;  and  between  them,  but  a  little  more  internally,  the  trochle- 
aris.  That  portion  of  the  vault  which  appertains  to  the  os  frontis 
is  so  thin  and  brittle  that  it  might  be  perforated  by  the  point  of 
the  bistoury  in  extirpating  the  eye,  if  proper  precautions  were  not 
taken.  The  tenuity  of  the  bone  also  renders  it  objectionable,  in 
this  operation,  to  apply  the  actual  cautery  upon  the  parts  which 
might  be  attached  to  it,  because  the  dura  mater  and  the  anterior 


OF   THE   HEAD. 

lobe  of  the  cerebrum  would  be  acutely  irritated  by  the  evolution 
of  the  igneous  particles.  It  is  also  in  consequence  of  this  ana- 
tomical disposition  that  instruments  penetrating  into  the  upper 
part  of  the  orbit  so  frequently  give  rise  to  serious  accidents,  even 
death  itself.  In  fact,  they  traverse  the  bone  with  the  greatest 
facility,  and  then  lacerate  the  brain.  Finally,  it  is  through  this 
part  that  balls  get  into  the  cavity  of  the  cranium,  when  they  have 
entered  by  the  orbit;  it  is  through  this  that  Garengeot,  J.  L. 
Petit,  etc.  have  seen  ram-rods,  swords,  etc.  penetrate  into  the 
skull  and  occasion  death,  and  it  is  but  recently  we  observed  a 
case,  in  a  student  at  law,  who  died  at  the  hospital  of  la  Faculte, 
where  a  ball  passed  into  the  cranium  at  this  part,  crossed  the 
whole  extent  of  the  lateral  ventricle,  tearing  up  the  parietes  of 
this  cavity,  and  lodged  in  one  of  the  superior  occipital  fossa?. 

On  the  outer  side  of  this  paries,  and  near  the  edge  of  the  orbit, 
is  the  fossette  in  which  the  lachrymal  gland  is  situated.  This 
excavation  is  sometimes  pretty  deep,  and  requires  attention  when 
we  extirpate  the  eye,  if  we  wish  to  remove  the  gland  at  the 
same  time. 

The  floor  of  the  orbit  is  triangular,  but  more  plane  than  the 
latter.  It  is  formed,  anteriorly  and  externally,  by  the  os  malae;  in 
its  most  posterior  part,  by  the  superior  surface  of  the  orbital  pro- 
cess of  the  os  palati,  and  throughout  the  rest  of  its  extent  by  the 
superior  wall  of  the  maxillary  sinus  The  two  sutures  which 
unite  these  three  bones,  adhere  pretty  firmly  to  the  periosteum, 
and  give  passage  to  some  small  emissary  veins.  This  paries  is 
grooved  out  in  its  two  posterior  third  portions  by  the  infra-orbi- 
tal gutter,  through  which  the  nerve,  artery  and  vein,  of  the  same 
name,  take  their  course  ;  these  organs,  therefore,  may  be  wounded 
by  an  injury  inflicted  upon  the  floor  of  the  orbit.  The  anterior  third 
of  this  gutter  is  converted  into  a  canal,  which  conducts  the  same 
organs  into  the  fossa  canina.  As  the  floor  of  the  orbit  is  very  thin, 
and  corresponds  to  the  maxillary  sinus,  tumours  which  are  deve- 
loped in  the  latter  cavity  tend  to  compress  the  eye,  and,  if 
greatly  enlarged,  to  thrust  it  outwards.  Pointed  instruments  also 
may  easily  penetrate  into  this  sinus ;  hence  it  has  happened  that 
surgeons,  in  operating  for  fistula  lachrymalis,  by  directing  the  point 
of  the  bistoury  too  much  outwards  or  backwards,  have  thrust  it 


72  OF    THE    HEAD. 

into  this  cavity,  and  afterwards  have  introduced  the  canula  into 
the  same  place,  considering  it  to  be  the  nasal  canal. 

The  internal  wall,  placed  in  the  direction  of  the  horizontal  axis 
of  the  head,  is  formed,  anteriorly,  by  the  posterior  half  of  the  ex 
ternal  face  of  the  os  unguis,  upon  which  the  muscle  of  Homer 
is  attached,  and  by  the  plane  surface  of  the  ethmoid ;  at  its 
most  posterior  part,  by  a  small  portion  of  the  sphenoid  bone. 
The  sutures  which  connect  these  bones,  and  those  which  unite 
them  to  the  superior  and  inferior  parietes,  present  nothing  re- 
markable, unless  it  is  the  fronto-ethmoidal,  in  the  tract  of  which 
we  meet  with  the  internal  orbital  foramina,  through  which  the 
ophthalmic  artery  and  nerve  send  branches  into  the  cells  of  the 
ethmoid,  to  the  dura  mater  and  nose.  This  wall  is  also  very  thin, 
and  might  easily  be  fractured  during  the  extirpation  of  the  eye. 
For  this  reason  we  consider  it  best,  in  performing  this  operation, 
to  introduce  the  curved  scissars  flat-wise  along  the  internal  side 
of  this  organ,  in  order  to  divide  its  pedicle,  rather  than  to  pass  it 
along  the  external  paries. 

The  external  wrall  is  formed  by  the  os  malae  anteriorly,  and  by 
the  great  ala  of  the  sphenoid  posteriorly ;  it  is  firm  and  solid,  and 
corresponds  to  the  temporal  fossa ;  it  is  separated  from  the  vault 
by  the  sphenoidal  fissure.  This  fissure  encloses  internally,  where 
it  is  broadest,  a  pedicle,  from  which  arise,  in  part,  the  superior, 
external  and  inferior  recti  muscles ;  the  third,  fourth,  ophthalmic 
branch  of  the  fifth,  and  sixth  pair  of  nerves ;  the  lachrymal  vein. 
A  cutting  instrument  might  be  easily  pushed  through  it,  and  wround 
the  middle  lobe  of  the  cerebrum. 

The  spheno-maxillary  fissure  separates  the  external  and  infe- 
rior regions  of  the  orbit.  Less  complicated  than  the  preceding, 
it  is  filled  with  fat  and  a  dense  fibro-cellular  tissue  ;  we  also  see 
in  it  the  infra-orbital  nerve  and  vessels.  Foreign  bodies  entering 
in  at  the  eye,  or  orbit,  might  easily  penetrate  through  it  into  the 
zygomatic  and  pterygo-maxillary  fossae ;  therefore,  in  the  extir- 
pation of  the  eye,  we  should  be  careful  how  we  dip  the  bistoury 
in  this  direction,  for  we  might  wound  the  internal  maxillary  ar- 
tery, the  supra-maxillary  nerve,  the  ganglion  of  Meckel,  etc. 

This  external  wall  is  very  oblique  outwards,  which  makes  it 
appear  shorter  than  the  internal.  The  conjoined  base  of  these 


OF   THE  HEAD.  73 

four  surfaces  forms  the  orbitary  circle,  which  is  obtuse  and  round- 
ed in  its  internal  half,  but  more  or  less  acute  in  its  external  por- 
tion. Therefore,  in  extirpating  the  eye,  we  should  introduce  the 
bistoury  at  the  great  angle,  carry  it  along  the  internal  paries,  and 
afterwards  follow  the  inferior  semi-circumference  of  the  orbital 
cavity  until  it  reaches  the  temporal  angle,  then  bring  back  the 
instrument  to  the  point  where  first  introduced,  and  complete  the 
circle  by  following  the  superior  paries.  This  method  is  not  only 
the  most  speedy,  but  it  is  likewise  attended  with  less  risk  of  in- 
troducing the  point  of  the  instrument  into  the  sphenoidal  and 
spheno-maxillary  fissures  than  if  we  should  commence  at  the 
external  angle.  In  the  first  incision,  according  to  this  process, 
we  only  separate  the  palpebral  from  the  ocular  conjunctiva,  the 
external  oblique  muscle,  and  the  cellular  tissue  which  unites  the 
muscles  to  the  orbit ;  in  the  second,  we  cut  the  double  tendon  of 
the  trochlearis  and  a  layer  of  cellular  tissue,  which  is  a  little 
more  dense  than  inferiorly.  Then  the  lachrymal  gland  is  sepa- 
rated from  its  fossette,  if  we  carry  the  bistoury  sufficiently  near 
the  bones.  The  eye  is  now  connected  to  the  apex  of  this  cavity 
merely  by  a  pedicle,  which  is  composed  of  the  four  recti,  troch- 
learis, and  levator  palpebrse  muscles,  of  the  ophthalmic  vessels, 
optic  nerve,  and  all  the  other  nerves  of  the  orbit ;  which  pedicle 
is  easily  divided  with  one  stroke  of  the  scissars. 

The  apex  of  the  orbit  being  very  narrow,  the  eye  is  with  diffi- 
culty drawn  back  into  it,  even  if  there  should  be  no  fat  to  pre- 
vent it. 

Sect.  4.  Zygomato-Maxillary  Region. 

It  comprises  all  the  parts  which  compose  the  pommette*  (ma- 
lar protuberance),  on  the  one  hand,  on  the  other  the  canine  fossa, 
arid  all  the  organs  which  cover  it.  It  is  bounded,  superiorly,  by 
the  orbitary  region  ;  inferiorly,  by  the  genial  region :  externally. 
by  the  temporal  and  masseteric  regions,  and  internally,  by  the  na- 
sal region. 

This  region  presents,  superiorly  and  externally  the  jugal  emi- 
nence, which  is  more  or  less  sharp  or  rounded,  more  or  less  prom- 

*  Pommette— the  name  which  French  anatomists  give  to  the  prominent  part 
which  the  face  presents  below  the  external  angle  of  each  eye.  This  part  is  formed 
by  the  integuments  and  os  malae. — Transl. 

10 


74  OF   THE    HEAD, 

inent,  according  to  the  nation,  age,  sex,  and  individual,  and 
which  has  much  influence  over  the  expression  of  the  counte- 
nance. Internally,  and  below  this  protuberance,  there  is,  in 
many  subjects,  a  groove,  which  runs  obliquely  downwards  and 
outwards,  extending  from  the  great  angle  of  the  eye  to  the  geni- 
al region,  and  separating  the  fossa  canina  from  the  malar  protu- 
berance (poinmettc) :  this  is  the  naso  jugal  furrow,*  above  which 
wre  find  the  orbicularis  palpebrarum  and  superior  portion  of  the 
zygomatic  muscles,  which  it  crosses ;  below  it  are  the  levators 
of  the  nose  and  lip,  and  the  buccinator.  Another  oblique  furrow 
extends,  in  the  same  direction,  from  the  ala  nasi  to  the  angle  of 
the  lips ;  this  is  the  naso-labial  furrow,  which  separates  the  labial 
region  from  the  one  under  consideration,  and  which  is  more  con- 
stant than  the  preceding.! 

CONSTITUENT    PARTS. 

i.  The  Skin. 

It  is  generally  smooth  and  delicate,  more  highly  coloured  upon 
the  jugal  prominence :  it  is  upon  this  point  that  the  febrile  blush 
appears  in  pulmonary  inflammations,  that  the  yellow  or  dirty 
tint  is  manifest  in  diseases  of  the  liver  and  internal  suppurations. 
Inferiorly,  and  externally,  but  in  man  only,  it  is  covered  with  a 
few  hairs ;  a  great  number  of  follicles  exist  in  it,  in  which  tanncs 
(acne  punctata)  sometimes  form  and  sometimes  undergo  chronic 
enlargement  forming  what  are  called  the  gutta  rosea. 

n.  The  Adipo-Cellular  Tissue. 

It  forms  a  layer  which  varies  in  thickness  according  to  the  de- 
gree of  obesity  of  the  individual,  and  also  according  as  it  corres- 
ponds to  the  muscles  or  their  interstices.  Upon  the  malar  emin- 
ence it  is  dense,  filamentous  and  contains  but  few  adipose  cells  ; 
and  as  it  is  the  only  part  which  exists  between  the  skin  and  the 

*  M.  Jadelot  calls  this  furrow  the  oculo- zygomatic  trait,  and  considers  it  a  diagnos- 
tic sign  of  diseases  of  the  cerebro-spinal  system  in  children. 

f  This  M.  Jadelot  calls  the  nasal  trait,  and  refers  it  to  affections  of  the  abdomina 
organs. 


OF    THE    HEAD.  75 

bones,  it  is  consequently  very  adherent  in  this  situation ;  there- 
fore, it  is  important,  when  we  operate  upon  the  face,  to  pre- 
serve as  much  of  this  adipo-cellular  tissue  as  possible,  otherwise, 
from  its  unyielding  nature,  the  lips  of  the  wound  will  not  come 
into  contact  so  as  to  unite  by  the  first  intention.  Internally  and 
interiorly  the  cellular  layer  is  very  thin,  and  the  adipose  vesicles 
which  it  contains  are  small  and  few  in  number  :  it  unites  the  skin 
intimately  to  the  levatores  labii  superioris  et  ala3  nasi.  This  com- 
pact union  renders  its  inflammations  very  painful,  and  gives  them 
an  erysipelatous  rather  than  a  phlegmonous  character.  In  the 
fossa  canina  the  cellular  lamellae  are  more  lax ;  the  adipose  vesi- 
cles very  large  and  numerous.  They  dip  between  the  muscles, 
fill  the  osseous  excavation,  and  communicate  with  those  of  the 
genial  region.  They  envelope  all  the  vessels  and  nerves,  and  as 
they  do  not  adhere  firmly  to  the  skin,  it  follows  that  we  can  bring 
its  wounds  together  by  means  of  straps,  bandages,  or  sutures,  bet- 
ter than  upon  the  malar  eminence,  so  as  to  induce  them  to  heal 
by  the  adhesive  union.  Finally,  as  this  cellular  layer  is  thicker 
and  its  meshes  farther  asunder  in  the  canine  fossa  than  internally 
and  externally,  it  follows  that  inflammations  are  more  frequent  in 
it,  and  more  liable  to  terminate  in  suppuration. 

in.  The  Muscles, 

In  this  region  we  find,  in  proceeding  from  the  nose  towards  the 
malar  eminence  the  levator  labii  superioris  aloeque  nasi,  the  leva- 
tor  labii  superioris  proprius  and  the  zygomatici  muscles  which 
converge  as  they  descend,  and  adhere  to  the  skin  or  are  sepa- 
rated from  it  by  the  cellular  layer  only.  It  is  necessary  to  keep 
in  mind  their  direction  when  we  operate  upon  the  face,  because 
their  transverse  section  would  derange  the  motions  of  the  mouth. 
Behind  the  first,  consequently  deeper  seated,  we  find  the  dilatator 
vel  compressor  naris  (transversal  du  wz),  concealed  by  the  leva- 
tor  communis,  and  the  levator  anguli  oris  which  partly  covers  the 
levator  proprius  and  sometimes  a  small  portion  of  the  zygomatr- 
cus  minor.  The  levator  anguli  oris  is  separated  from  the  inter- 
nal membrane  of  the  lips  only  by  a  thin  but  dense  laminated 
tissue.  Between  the  inferior  loops  of  the  orbicularis  palpebrarum, 
the  levator  proprius  and  zygomatici,  there  is  generally  a  consid- 


70  OF    THE   HEAD. 

erable  space,  which  is  filled  only  by  the  celiulo-adipose  layer, 
vessels  and  nerves,  and  by  which  wre  penetrate  into  the  fossa 
canina. 

iv.  The  Arteries. 

They  either  terminate  in  this  region  or  simply  pass  through  it. 
The  infra-orbital  artery  comes  out  of  the  sub-orbital  foramen, 
which  is  opposite  to  the  middle  of  a  line  drawn  from  the  inferior 
margin  of  the  os  nasi  to  the  lower  part  of  the  malar  eminence, 
and  enters  the  canine  fossa.  It  is  situated  behind  the  levator 
proprius  muscle,  on  a  level  with  its  external  border,  before  and 
above  the  levator  anguli  oris.  It  is  separated  from  the  os  max- 
illare  superius  by  the  nerves  and  cellular  tissue,  and  from  the 
orbicularis  palpebrarum  muscle,  by  the  facial  vein  and  adipose 
vesicles.  This  artery  is  distributed  to  the  nasal  and  labial  regions, 
and  anastomoses  with  their  proper  vessels.  The  transverse 
facial  artery,  which  terminates  in  this  region  below  the  jugal 
prominence,  is  sometimes  so  large  as  to  occasion  hemorrhage ; 
but,  as  it  creeps  through  a  lax  lamellated  tissue,  it  may  be  readily 
secured,  if  it  should  become  necessary.  The  facial  artery  gene- 
rally runs  along  the  internal  and  inferior  limits  of  this  region, 
traversing  the  levatores  anguli  oris  et  labii  proprius,  behind  the 
naso-labial  furrow ;  it  then  reaches  the  great  angle  of  the  eye, 
where  it  anastomoses  with  the  ophthalmic,  after  having  received 
the  name  angularis. 

v.  The  Veins. 

The  facial  vein  is  the  only  one  which  merits  some  attention. 
It  does  not  follow  the  direction  of  the  arteries,  which,  for  the 
most  part,  (the  infra-orbital  excepted)  have  no  venae  comites. 
This  vessel  runs  in  an  almost  direct  line  from  the  internal  angle 
of  the  eye,  and  seems  to  be  the  continuation  of  the  frontal :  near 
its  origin  it  communicates  with  the  veins  of  the  orbit ;  before 
the  masseter,  as  it  passes  beneath  the  naso-jugal  furrow,  it  is  sub- 
cutaneous, or  covered,  superiorly,  by  the  inferior  fibres  of  the 
orbicularis  palpebrarum  muscle :  inferiorly,  it  is  enveloped  in  the 
celiulo-adipose  tissue  which  separates  the  zygomatici  from  the 


OF   THE    HEAD.  77 

levator  anguli  oris  and  buccinator  muscles,  and  is  crossed  ante- 
riorly by  the  ramifications  of  the  facial  nerve ;  posteriorly  by  the 
buccal  and  infra-orbital  nerves. 


vi.  The  Lymphatics. 

They  are  few  in  number  and  pass  to  the  submaxillary  lymph- 
atic glands.  No  absorbent  glands  have  as  yet  been  discovered  in 
this  region. 

vn.  The  Nerves. 

We  here  find  the  termination  of  the  superior  maxillary  or 
infra-orbital  nerve,  which  is  at  first  situated  on  the  outer  side  of 
the  artery ;  its  branches  then  diverge  and  are  lost  in  the  skin 
of  the  lips,  nose,  cheek  and  that  which  covers  the  inferior  or- 
bital arch,  anastamosing  in  most  of  these  points  with  filaments 
from  the  fascial.  When  we  are  perfectly  satisfied  that  this  nerve 
is  the  cause  of  the  tic  douloureux  of  the  face,  and  desire  to  divide 
it,  we  may  easily  fall  upon  it,  between  the  orbicularis  palpebra- 
rum  and  the  origin  of  the  levator  labii  proprius,  by  cutting  upon 
the  naso-jugal  furrow.  We  would  then  have  to  reflect  the  facial 
vein  outwards,  and  the  levator  inwards ;  the  skin  and  cellular 
tissue  being  thus  divided,  we  will  see  the  nerve  very  near  the 
origin  of  the  levator  anguli  oris.  This  method  appears  to  us  to 
be  more  simple  than  that  of  Langenbeek.* 

The  zygomato-maxillary  region  also  receives  numerous  fila- 
ments from  the  temporo-facial  branch  of  the  respiratory  of  the 
face  (portio  dura).  They  generally  cross  the  anterior  surface  of 
the  vessels,  and  are  at  first  enveloped  in  the  subcutaneous  layer ; 
afterwards,  lost  in  the  muscles.  The  investigations  and  experi- 
ments of  Shaw,  Charles  Bell,  etc.,  render  it  probable,  if  not  cer- 
tain, that  the  muscular  movements  of  this  region  are  under  the 
influence  of  the  portio  dura ;  whilst  the  infra-orbital  nerve  pre- 
sides over  the  sensitive  functions.  There  are  also  some  small 
filaments  from  the  lachrymal  which  anastomose  upon  the  os  ma- 
lae ;  but  they  can  only  serve  to  explain  some  sympathetic  affec- 
tions. 

*  Bibliotbeque  Chirurg.  No.  de  1821. 


78 


OF    THE    HEAD. 


viii.  The  Skeleton. 

In  this  region  we  find  the  os  malae,  which,  although  possessing 
considerable  solidity,  is  nevertheless  exposed  to  fracture,  on  ac- 
count of  its  superficial  situation,  externally  especially,  where  it  is 
no  longer  supported  by  the  superior  maxillary  bone.  From  it  the 
two  zygomatic  muscles  originate  ;  but  more  superiorly,  and  pos- 
teriorly, it  is  only  separated  from  the  skin  by  the  dense  cellular 
tissue  before  mentioned,  by  the  malar  branches  of  the  facial  nerve, 
the  malar  twigs  of  the  lachrymal  artery  and  nerve,  as  well  as  the 
transverse  facial  branch.  In  consequence  of  this  dense,  nervous 
and  vascular  texture,  the  inflammations  which  occur  upon  the 
malar  emim  nee  are  very  painful,  and  the  skin  which  covers  it  is 
more  sensib  e  and  higher  coloured.  The  os  maxillare  superius 
presents,  in  ttiis  region,  all  the  anterior  wall  of  the  antrum,  into 
which  it  would  be  much  easier  to  penetrate,  by  following  the 
method  recommended  for  the  division  of  the  infra-orbital  nerve, 
than  by  acting  upon  the  obtuse  crest  which  separates  the  fossa 
eanina  from  the  malar  tuberosity,  as  recommended  by  Lamorier. 
This  wall  of  the  sinus  is  so  thin  and  brittle,  that  it  might  be  perforat- 
ed without  much  difficulty,  even  by  an  instrument  with  a  rounded 
extremity :  but  then  the  anterior  dental  nerves,  derived  from  the  in- 
fra-orbital previous  to  its  entrance  into  the  fossa  eanina,  must  be 
torn  or  stretched  out  of  their  place.  How  much  more  liable  then 
is  it  to  be  traversed  by  a  pointed  instrument :  a  small  sword,  for 
instance,  if  thrust  violently  upwards  and  backwards,  might  even 
penetrate  through  the  floor  of  the  orbit,  after  having  passed  through 
this  sinus,  and  thus  wound  the  different  parts  contained  within  it ; 
and  if  the  force  with  which  it  is  pushed  is  not  exhausted,  it  will 
break  through  the  orbitaiy  vault,  and  entering  the  cranium,  lead  to 
mortal  consequences.  The  position  of  this  sinus  also  permits  pol- 
ypi, which  are  developed  within  it,  to  become  prominent  upon  the 
face,  after  having  destroyed  its  anterior  paries.  The  periosteum 
in  this  region,  is  not  very  compact  upon  the  maxillary  bone,  and 
it  is  easily  separated  from  it  by  inflammation.  This,  therefore, 
accounts  for  necrosis  and  caries  being  very  frequently  attendant 
upon  diseases  of  the  teeth,  etc. 


OF   THE    HEAD.  79 


Sect.  5.  The  Masscteric  Region. 

It  is  bounded  by  the  margins  and  attachments  of  the  masseter 
muscle.  Consequently,  we  find  anterior  to  it  the  zygomato-max- 
illary  and  genial  regions ;  posteriorly,  the  parotideal ;  superiorly, 
the  temporal ;  and  inferiorly,  the  supra-hyoideal  regions. 

Upon  the  face  of  most  subjects,  it  forms  a  prominence  which 
varies  in  proportion  to  the  size  of  the  parotid  and  masseter,  and 
especially  to  the  inclination  of  the  angle  of  the  jaw. 

CONSTITUENT  PARTS. 

i.  The  Skin. 

This  is  thicker  than  the  skin  of  the  parotideal  and  genial  re- 
gions, and  of  a  compact,  unyielding  texture.  In  man,  it  is  cov- 
ered with  a  great  number  of  hairs,  contains  also  sebaceous  folli- 
cles, but  presents  nothing  remarkable  in  a  surgical  point  of  view. 

ii.  The  Subcutaneous  Layer. 

This  layer  is  seldom  very  thick,  and  consists  of  a  lamellated 
cellular  tissue,  which  becomes  blended  with  the  fascia  of  the  par- 
otideal and  supra-hyoideal  regions,  is  lost  anteriorly  in  the  cellular 
tissue  of  the  genial  region,  gives  a  sheath  to  the  canal  of  Steno, 
envelopes  the  superficial  nerves  and  vessels,  and  is  separated  from 
the  skin  by  some  fibres  of  the  platysma.  This  stratum  may 
therefore  be  considered  as  being  formed  of  two  cellular  laminae  ; 
one  of  which  is  immediately  beneath  the  skin,  and  sometimes  en- 
velopes a  considerable  quantity  of  adipose  vesicles ;  the  other, 
which  is  more  dense,  invests  the  masseter,  and  forms  a  complete 
aponeurosis ;  whence  it  follows,  that,  in  wounds  of  this  region, 
we  may  employ  uniting  means  with  much  more  advantage  than  in 
the  other  points  of  the  face  ;  whence,  also,  tumours  and  abscess- 
es which  form  under  the  second  lamina,  remain  for  a  long  time 
flattened,  and  become  of  considerable  breadth  before  they  ele- 
vate the  skin ;  whereas  the  same  affections,  when  developed  be- 
neath the  first  lamina,  soon  become  quite  prominent.  These 


SO  OF   THE    HEAD. 

peculiarities  should  be  attended  to,  as  they  will  assist  us  in  forming 
our  diagnosis  or  prognosis  of  certain  diseases. 

m.  The  Muscles. 

There  is  only  one  muscle  on  the  outer  side  of  the  jaw,  which 
is  the  masseter.  It  originates  from  the  inferior  border  of  the 
zygomatic  arch  to  within  a  few  lines  before  its  horizontal  ramus. 
The  posterior,  anterior  and  middle  fibres  run  forwards,  back- 
wards, or  directly  downwards,  but  do  not  constitute  three  mus- 
cles, as  Winslow  describes  it.  The  masseter  muscle  cannot, 
when  the  jaw  is  depressed,  assist  in  luxating  this  bone  ;  but,  at 
the  moment  the  condyle  is  about  to  pass  into  the  zygomatic  fossa, 
its  posterior  fibres  may  draw  the  maxillary  angle  upwards,  and 
thus  concur  in  the  depression  of  the  chin.  This  muscle  is  fre- 
quently the  seat  of  rheumatism,  which  may  be  accounted  for  by 
the  quantity  of  fibrous  tissue  entering  into  its  composition  Its 
fibres  being  parallel  to  the  axis  of  the  body,  and  no  important 
vessel  crossing  it,  the  incisions  which  we  make  in  this  region 
should  be  as  near  the  perpendicular  as  possible.  We  must  pay 
attention,  however,  to  the  parotid  duct  which  crosses  the  superior 
part  of  this  muscle. 

iv.  The  Arteries. 

The  superficial  branches  are  derived  from  the  external  carotid 
and  facial,  a  deep  branch  from  the  internal  maxillary.  The  trans- 
verse facial  originates  from  the  former ;  it  crosses  the  muscle,  en- 
veloped in  the  lamina?  of  the  aponeurosis,  four  or  five  lines  below 
the  zygomatic  arch,  and  one  or  two  lines  above  the  parotid  duct ; 
it  then  enters  the  zygomato-maxillary  and  genial  regions,  and 
anastomoses,  inferiorly  and  anteriorly,  with  the  twigs  which  are 
detached  from  the  facial  as  it  passes  before  the  masseter.  It  is 
sometimes  so  large  as  to  occasion  hoemorrhage.  There  are,  in 
certain  individuals,  one  or  more  transverse  facial  arteries  below 
the  canal  of  Steno,  but  they  are  generally  so  small  that  they 
scarcely  deserve  surgical  attention.  The  masseteric  artery,  in  its 
course  to  this  muscle,  passes  through  the  sigmoid  notch,  before  the 
maxillarv  condvle,  behind  the  tendon  of  the  temporalis  and  above 


OP    THE    HEAD.  SJ 

the  pterygoideus  externus,  so  that  it  may  be  compressed  or  lace- 
rated when  the  condyle  of  the  lower  jaw  is  luxated  or  fractured. 

v.  The  Veins. 

They  are  of  but  little  importance  to  the  surgeon :  some  of 
them  accompany  the  arteries,  the  others  take  a  distinct  course. 
They  generally  form  a  communication  between  the  facial  and 
external  jugular  veins ;  but  they  empty  more  especially  into  the 
latter. 

vr.  The  Lymphatics. 

These  vessels  are  more  numerous  in  this  than  in  the  other 
regions  of  the  face,  and  pass  into  the  submaxillary  and  parotideal 
lymphatic  glands ;  whence  the  rapid  engorgement  which  takes 
place  in  the  latter  organs  in  some  diseases  of  the  masseteric 
region. 

vii.   The  Nerves. 

One  of  them  comes  from  the  inferior  maxillary,  follows  the 
masseteric  artery,  and  is  lost  in  the  masseter  muscle.  The 
others  are  the  temporo-facial  and  cervico-facial  branches  of  the 
respiratory  nerve  of  the  face.  The  first  forms  a  complete  net- 
work in  the  aponeurosis  above  and  below  the  duct  of  Steno  and 
the  transverse  facial  artery.  The  filaments  of  the  second  being 
less  numerous,  it  follows  that  wounds  are  less  dangerous  in  the 
inferior  than  the  superior  part  of  the  region. 

vni.  The  Canal  of  Steno.     (Parotid  Duct.) 

This  canal  having  emerged  from  the  parotid,  crosses  the  mas- 
seter, upon  which  it  is  immediately  applied.  We  have  previously 
said  that  it  received  a  sheath  from  the  aponeurosis.  It  is  covered 
by  nerves,  the  largest  of  which  run  above  it,  and  upon  its  supe- 
rior margin  also  lies  the  transverse  facial  artery.  It  is  situated 
eight  or  nine  lines  below  the  zygomatic  arch,  posteriorly ;  three 
or  four  only,  anteriorly.  Between  it  and  this  arch  there  is  some- 

11 


8*2  OF    THE    HEAD. 

times  a  distinct  glandular  lobule,  which  is  the  accessory  of  the 
parotid.  The  presence  of  this  canal  must  make  us  very  circum- 
spect in  forming  our  diagnosis  or  prognosis  of  wounds  or  ulcers 
of  this  region,  as  well  as  in  the  performance  of  operations  upon 
it.  In  fact,  as  it  is  more  or  less  superficial,  in  proportion  to  the 
embonpoint  of  the  individual,  it  might  be  readily  opened  and  give 
rise  to  fistulous  wounds  of  very  difficult  cure ;  especially,  as 
salivary  fistulse,  in  this  situation,  do  not  admit  of  the  employment 
of  M.  Deguise's  method,  the  only  chance  of  success  being  af- 
forded by  the  use  of  the  caustic  or  setons. 

ix.  The  Skeleton. 

It  comprehends  the  zygomatic  arch  and  the  whole  ramus  of 
the  jaw.  The  superficial  position  of  the  arch,  and  the  slender- 
ness  of  the  bones  which  compose  it,  render  it  very  susceptible  of 
fracture  from  a  direct  cause.  These  fractures  are  not  dangerous 
from  the  derangement  of  function  which  the  displaced  fragments 
produce,  but  in  consequence  of  the  inflammation  and  abscesses 
which  may  supervene  in  the  temporal  or  zygomatic  fossae.  An 
instrument  introduced  under  this  arch  would  easily  penetrate 
into  the  zygomatic  fossa,  and  even  enter  the  cranium,  if  its 
point  was- directed  slightly  upwards;  from  which  might  result  a 
wound  of  the  middle  meningeal  artery,  etc. 

The  ramus  of  the  inferior  maxillary  bone   presents,  in  this 
region,  three  points  for  consideration :    1st.  the  angle,  which  is 
curved  outwards  in  some  individuals,  and  upon  which  the  princi- 
pal force  is  applied  in  indirect  fractures  of  the  body  of  this  bone ; 
2d.  the  condyle,  which  may  be  fractured  at  its  neck,  and  as  the 
pterygoid,  in  this  case,  draws  its  inferior  portion  forwards,  the 
reduction  is  rendered  very  difficult ;    3d.  the  coronoid  process, 
which  prevents  the  luxation  of  the  condyle,  excepting  when  the 
jaws  are   extensively   separated ;    for   otherwise,   it   would   be 
checked  by  the  posterior  face  of  the  os  malae.     As  this  process 
is  enveloped  by  the  tendon  of  the  temporal  muscle,  if  it  was 
detached  from  the  rest  of  the  bone,  it  would  be  drawn  towards 
the  temporal  fossa.      In  the  interval  of  these  three  parts,  the 
ascending  portion  of  the  jaw  is  entirely  covered  by  the  attach- 
ments of  the  masseter ;  so  that  a  fracture  of  this  part  will  rarely 


OF    THE    HEAD.  83 

be  attended  with  displacement.  Internally,  this  bone  forms  a 
part  of  the  zygomatic  ibssa,  which,  as  it  may  be  considered  an 
appendage  to  the  masseteric  region,  we  will  now  examine. 

This  fossa  encloses  the  two  pterygoid  muscles,  which  are  so 
disposed  that  the  external  is  rather  a  depressor  of  the  lower  jaw 
than  its  elevator.  Between  these  two  muscles,  we  find  the  infe- 
rior dental  artery  and  nerve,  the  internal  ligament  of  the  articu- 
lation, the  lingual  branch  of  the  fifth  (gustatory)  etc.,  descend- 
ing in  an  oblique  direction  ;  quite  internally,  the  levator  and  cir- 
curnflexus  palati,  and  the  superior  constrictor  pharyngeus :  the 
space  which  intervenes  between  the  latter  and  the  former  is 
filled  by  a  lamellated  tissue,  and  frequently  by  a  process  of  the 
parotid  gland.  It  is  in  the  upper  part  of  this  space  that  we  find 
the  different  branches  of  the  inferior  maxillary  nerve  enveloped  by 
the  fibres  of  the  origin  of  the  external  pterygoid.  Consequently, 
we  also  find  here  the  auricular  nerve,  which  originates  from  the 
trunk  by  two  roots,  between  which  the  middle  meningeal  artery 
passes  ;  the  gustatory  and  dental,  which  here  form  a  communica- 
tion with  each  other  by  means  of  a  cord  of  greater  or  less 
volume ;  the  gustatory  also  receives,  in  this  situation,  the  corda 
tympani.  These  three  branches  are  situated  behind  the  external 
pterygoid.  We  also  see,  in  the  fibres  of  this  muscle,  above  or 
before  it,  the  masseteric,  temporal,  buccal,  and  pterygoidean 
twigs ;  whence  it  follows  that  the  former  would  be  easily  reached 
by  an  instrument  which  would  traverse  the  sigmoid  notch*  of 
the  inferior  maxillary  bone  ;  but  if  we  wish  to  divide  them,  we 
can  only  succeed  by  detaching  the  parotid  and  the  arteries  from 
the  posterior  margin  of  the  jaw,  between  the  twro  branches  of  the 
facial;  and  even  then  we  might  only  reach  the  dental  and 
gustatory. 

The  internal  maxillary  artery  and  its  thirteen  branches  are 
also  distributed  in  this  fossa ;  all  these  branches,  except  the  me- 
ningea  media,  are  accompanied  by  veins  which  empty  into  the 
jugulars,  and  which  establish  relations  in  the  circulation  between 
the  nose,  orbit,  and  parotideal  region,  which  the  pathologist 
should  not  be  ignorant  of. 

At  the  anterior  part  of  the  bottom  of  the  zygomatic  fossa  is 

*  The  sigmoid  notch  separates  the  condyle  from  the  coronoid  process.— Transl. 


84  OF    THE    HEAD. 

the  pterygo-maxillary  fissure,  in  which  we  find,  from  above 
downwards,  the  superior  maxillary  nerve,  which  passes  from  the 
cranium  into  the  orbit,  the  spheno-palatine  ganglion  and  the 
origin  of  its  vidian,  palatine,  spheno-palatine,  etc.  branches ;  the 
termination  of  the  internal  maxillary  artery,  which  there  gives 
off  the  spheno-palatine,  pterygo-palatine,  vidian  and  superior 
palatine  arterial  branches.  We  may  easily  pass  an  instrument 
through  the  spheno- maxillary  fissure  of  the  orbit  into  this  fos- 
sette,  and  we  perceive  how  dangerous  wounds  in  this  point 
would  be.  The  bones  which  compose  the  pterygo-maxillary 
fossa  are  somewhat  numerous.  Its  anterior  paries  is  formed  by 
the  posterior  part  of  the  superior  maxillary  bone,  which  is  perfo- 
rated by  a  great  number  of  small  holes  for  the  transmission  of 
the  superior  and  posterior  dental  filaments,  and  which  will  bulge 
out  more  or  less,  according  as  the  last  molar  tooth  is  contained 
within  it  or  not.  It  is  in  the  upper  and  outer  part  of  this  paries 
that  we  see  the  commencement  of  the  infra-orbital  groove.  The 
anterior  surface  of  the  pteiygoid  process,  perforated  at  its  base 
by  the  Vidian  foramen,  forms  the  posterior  paries ;  the  internal 
is  constituted  by  the  external  surface  of  the  os  palati.  It  is  hol- 
lowed out  and  converted  inferiorly  into  a  canal,  in  the  formation 
of  which  the  anterior  paries  of  the  fossa  concurs :  this  is  the 
posterior  palatine  canal,  along  which  the  artery  and  nerve  of  the 
same  name  pass  to  the  mouth.  In  the  upper  part  of  this  paries, 
we  see  the  pterygo-palatine  foramen,  through  which  vessels  and 
nerves  penetrate  into  the  nasal  fossae.  Polpyi  of  the  nose  might 
also  make  their  way  through  this  foramen,  and  thus  get  into  the 
zygomatic  fossa.  We  saw  a  remarkable  case  of  this  kind  in 
1823.  The  superior  paries  of  the  zygomatic  fossa  does  not  exist, 
properly  speaking  ;  it  falls  into  the  sphenoidal  fissure  and  enters 
the  cranium. 

The  bones  which  enter  into  the  zygomatic  fossa,  properly  so 
called,  are,  anteriorly,  the  concave  part  of  the  os  mate,  then  the 
external  surface  of  the  molar  portion  of  the  supra-maxillary  bone  ; 
superiorly,  the  zygomatic  portion  of  the  great  ala  of  the  sphenoid, 
to  which  the  external  pteiygoid  muscle  is  attached ;  internally, 
the  external  surface  of  the  pterygoid  process  ;  and  externally  the 
ramus  of  the  jaw,  in  the  middle  of  which  we  observe  the  orifice 
of  the  dental  canal :  a  disposition  which  explains  why  fractures 


OF    THE    HEAD.  85 

of  the  neck  of  the  condyle,  &c.,  less  frequently  produce  serious 
accidents  than  those  which  correspond  to  this  foramen. 

Sect.  6.     The  Genial  Region. 

It  is  wedged  as  it  were  between  the  mental,  labial,  zygomato- 
maxillary,  masseteric  and  sub-maxillary  regions.  Its  limits  can- 
not be  otherwise  than  arbitrary,  and  its  surgical  importance  is 
particularly  derived  from  salivary  fistula  and  the  passage  of  the 
facial  artery.  It  is  sometimes  prominent,  at  others  excavated, 
and  in  many  individuals  it  presents  one  or  two  fossettes,  which 
are  owing  to  the  contraction  of  the  muscles. 

CONSTITUENT    PARTS. 

i.   The  Skin. 

The  skin  is  delicate  and  smooth  in  women  and  children,  but 
in  man  it  is  covered  by  the  hairs  of  the  beard  ;  and  although  it  is 
not  intimately  adherent  to  the  subjacent  parts,  yet  it  does  not 
move  so  freely  over  them  as  in  the  masseteric  region. 

ii.  Tlie  Cellulo- Adipose  Tissue. 

It  forms  a  considerable  mass  anterior  to  the  masseter,  between 
the  buccinator  and  the  integuments,  and  is  thereby  continuous 
posteriorly  with  that  of  the  temporal  fossa  :  which  explains  the 
manner  in  which  abscesses  of  one  of  these  regions  communicate 
with  the  other.  The  absence  of  this  fatty  mass  occasions  the 
excavation  of  the  cheeks  in  thin  persons.  Iriferiorly  and  ante- 
riorly, the  adipose  cells  become  smaller  and  smaller,  and  at 
length  terminate  by  uniting  intimately  with  the  muscles  and  the 
skin,  so  that  phlegmonous  abscesses  are  more  easily  formed  pos- 
teriorly. 

The  cellular  tissue  is  dense  or  lax,  in  proportion  to  the  thickness 
of  the  adipose  layer.  Its  quantity  does  not  vary ;  but  its  lamel- 
lae are  more  or  less  separated  from  each  other,  according  to  the 
volume  of  the  adipose  vesicles.  It  is  from  this  that  the  massete- 
ric aponeurosis  seems  to  originate. 


86  OF    THE    HE  Air 


in.  The  Muscles. 

The  facial  portion  of  the  platysma  frequently  forms  a  triangu- 
lar bundle,  the  base  of  which  is  at  the  masseter  and  the  apex  at 
the  angle  of  the  lips.  This  muscle  (risorius  Santorini)  is  some- 
times very  strong,  and  its  contractions  occasion  those  dimples 
(fossettes)  just  spoken  of,  which  add  to  the  beauty  of  the  female 
countenance.  It  is  situated  in  the  lamellae  of  the  subcutaneous 
cellular  tissue.  In  the  inferior  part  of  this  region,  and  separated 
from  the  skin  by  the  platysma,  is  the  depressor  anguli  oris,  the 
fibres  of  which  converge  as  they  approximate  the  labial  angle. 
The  buccinator  is  the  principal  muscle  in  this  region.  Posterior- 
ly, it  is  separated  from  the  skin  by  the  adipose  mass  previously 
spoken  of,  and  by  the  platysma  ;  anteriorly,  it  is  almost  in  direct 
contact  with  it.  Its  external  surface  is  covered  by  a  fibrous  ex- 
pansion which  is  given  off  by  the  parotid  duct  before  it  perfo- 
rates it :  this  expansion,  being  prolonged  backwards,  becomes 
blended  with  the  bucco-pharyngeal  aponeurosis,  which  attaches 
itself  to  the  base  of  the  coronoid  and  to  the  internal  ala  of  the 
pterygoid  process.  A  foreign  body,  a  sword,  for  example,  thrust 
between  this  aponeurosis,  which  is  internal,  the  masseter  and 
coronoid  process  which  are  external,  might  penetrate  into  the 
zygomatic  fossa,  even  to  the  bottom  of  the  parotideal  region,  and 
thereby  wound  the  internal  maxillary  artery,  the  inferior  maxilla- 
ry nerve,  the  internal  carotid  and  jugular,  the  parvagum,  great 
sympathetic,  etc.  Internally,  the  buccinator  is  separated  from 
the  buccal  membrane  by  a  dense  and  thin  cellular  lamina,  in 
which  is  found,  posteriorly,  the  molar  glands,  which  are  some- 
times very  large,  being  perfect  glands,  each  possessing  their  ex- 
cretory duct,  and  not  simple  follicles.  When  we  are  obliged  to 
make  incisions  on  the  inner  part  of  the  cheek  we  should  recollect 
that  the  fibres  of  the  buccinator  are  nearly  horizontal. 

iv.    The  Canal  of  Stcno. 

It  is  accompnnied  by  a  considerable  branch  of  the  facial  nerve 
and  terminates  in  this  region  by  curving  over  the  anterior  mar- 
gin of  the  masseter,  four  or  five  lines  before  which  it  penetrates 


OP   THE    HEAD.  87 

the  buccinator :  it  is  then  also  about  four  lines  distant  from  the 
malar  eminence.     From  this  disposition,  then,  it  follows,  that  the 
operation  of  M.  Deguise  for  the  cure  of  salivary  fistulas  is  not  so 
simple  as  might  be  supposed ;  for  the  posterior  extremity  of  the 
canula  or  tent  must  traverse  a  considerable  thickness  of  parts 
before  it  reaches  the  mouth ;  besides,  this  method  can  seldom  be 
applicable,  since  it  can  only  be  resorted  to  when  the  disease  ex- 
ists some  lines  anterior  to  the  masseter.     Now,  the  short  tract 
which  the  canal  has  to  traverse  in  this  place,  and  its  depth  in  this 
situation,  prevents  its  being  frequently  wounded  at  this  part. 
We  may  say  the  same  of  the  advice  which  we  gave  in  1823,* 
i.  e.  to  introduce  an  instrument  into  the  mouth,  and  make  an 
opening  in  the  canal  nearer  the  gland  than  the  fistulous  aperture 
in  the  skin.     So  with  tne  methods  of  Leroy,  J.  L.  Petit,  Duphenix, 
etc.  in  which  the  rule  is  to  perforate  the  cheek  in  any  manner 
whatsoever.     The  walls  of  the  parotid  duct  are  much  thicker  in 
the  genial  region,  so  that  its  volume  is  considerably  augmented  ; 
but  when  it  is  about  to  perforate  the  buccinator,  it  leaves  upon 
the  external  surface  of  this  muscle  the  fibrous  envelope  which 
it  had  derived  from  the  parotideal  aponeurosis ;  so  that  it  is  much 
more  slender  between  the  fleshy  fibres  than  before  it  penetrated 
them.     Its  internal  opening  is  four  or  five  lines  below  the  point 
where  the  mucous  membrane  unites  with  the  gums,  and  general- 
ly opposite  the  last  molar  tooth  but  one.     From  the  masseter  to 
the  orifice,  the  canal  of  Steno  represents  an  arc  of  a  circle  the 
convexity  of  which  looks  forwards  and  outwards.     Hence  the 
utility  of  everting  the  fore  part  of  the  cheek  with  one  or  two 
fingers  introduced  into  the  mouth,  whilst  we  push  inwards  with 
the  thumb  the  portion  in  proximity  with  the  muscle,  as  recom- 
mended by  Louis,  when  we  wish  to  introduce  a  stylet,  probe, 
seton,  etc.  into  it.     It  is  in  fact  this  curvature,  and  the  laxity  of 
the  organ,  which  oppose  the  introduction  of  instruments  into  the 
duct  by  the  mouth,  and  not  a  pretended  valve,  which  does  not 
really  exist. 

v.  The  Arteries. 
The  only  artery  of  importance  in  this  region  is  the  facial.     It 

*  Thdse  inaugurate. 


88 


OF   THE    HEAD. 


enters  the  region  at  the  lower  part  of  its  posterior  boundary  ;  that 
is  to  say,  before  the  masseter.     In  this  situation  it  lies  upon  the 
bone,  behind  the  depressor  anguli  oris,  being  separated  from  the 
skin  merely  by  cellular  tissue  and  the  platysma ;  so  that  we  are 
able  to  make  firm  compression  upon  it  here,  when  about  to  oper- 
ate upon  the  face.     It  would  also  be  very  easy  to  apply  a  ligature 
around  it,  if  any  diseases  of  the  organs  to  which  its  branches  are 
distributed  should  seem  to  demand  it.     If,  when  we  wish  to  com- 
press it,  the  edge  of  the  masseter  is  not  sufficiently  evident  through 
the  skin,  we  should  carry  the  finger  forwards  from  the  angle  of 
the  jaw,  when  we  will  soon   meet  with  a  superficial  notch  in 
which  the  artery  is  always  placed.     As  the  facial  artery  takes  its 
serpentine  course  from  this  point  towards  the  zygomato-maxillary 
region,  it  follows  the  direction  of  the  posterior  fibres  of  the  trian- 
gularis  (depressor  anguli  ora),which  it  traverses  in  order  to  enter 
the  zygomato-maxillary  region  :  the  inferior  coronary  is  given  off 
from  it  whilst  it  is  still  in  the  genial  region.      It  also  gives  off  a 
great  number  of  small  branches,  which  anastomose  posteriorly 
with  the  transverse  facial,  anteriorly  with  the  mental,  and  superi- 
orly with  the  infra-orbital :  all  these  branches,  in  fact,  terminate 
in  part  in  the  region  under  examination.     We  likewise  find  here 
the  buccal  coming  from  the  internal  maxillary,  upon  the  external 
surface  of  the  buccinator  muscle,  and  communicating  internally 
with  the  alveolares  and  inferior  dental ;  these  twigs,  however,  are 
of  no  importance  in  surgery. 

vi.  The  Veins. 

The  large  facial  vein  alone  merits  some  attention.  In  the  zygo- 
mato-maxillary region,  it  was  remote  from  the  artery ;  as  it  tra- 
verses the  genial  region,  it  approximates  it,  and  at  length  covers 
it,  when  about  to  pass  into  the  supra-hyoideal  region.  This  want 
of  parallelism  between  the  two  principal  vessels  of  the  face,  is 
owing  to  the  vein  being  free  from  curvatures  in  its  course  from 
the  great  angle  of  the  eye  to  the  fore  part  of  the  masseter,  whilst 
the  artery,  in  passing  through  the  same  tract,  is  very  tortuous. 
Furthermore,  notwithstanding  the  magnitude  of  the  vein  at  the 
lower  part  of  the  face,  it  would  be  dangerous  to  draw  blood  from 
it,  on  account  of  the  proximity  of  the  artery. 


OP    THE    HEAD.  89 


vii.  The  Lymphatics. 

These  vessels  are  as  yet  not  well  understood  ;  they  are  a  con- 
tinuation of  those  which  were  observed  in  the  upper  part  of  the 
face  ;  they  run  into  the  submaxillary  lymphatic  glands.  There 
are  also  some  deep-seated  vessels  which  pass  to  the  carotic  or  sub- 
mastoid  cervical  glandules. 

vm.  The  Nerves. 

The  nerve  which  appertains  to  this  region  is  spread  out  upon 
the  buccinator  muscle,  and  for  this  reason  is  called  buccal  (n : 
buccinatorius).  The  others  are,  anteriorly  and  superiorly,  fila- 
ments of  termination  from  the  mental  and  infra-orbital,  which 
appear  to  be  the  nerves  of  sensation ;  posteriorly,  some  filaments 
from  the  facial  (portio  dura),  which  rather  appertain  to  motion. 
We  have  already  mentioned  that  a  considerable  branch  accompa- 
nied the  superior  margin  of  the  parotid  duct. 

ix.  The  Mucous  Membrane. 

It  is  polished,  delicate,  very  adherent  to  the  cheek,  and  insinu- 
ates itself  into  the  canal  of  Steno,  which  it  lines  as  far  as  its  radi- 
cles. It  is  by  means  of  this  mucous  prolongation  that  the  paro- 
tids sometimes  become  sympathetically  inflamed  in  consequence 
of  diseases  of  the  mouth.  Where  this  membrane  is  reflected 
over  the  dental  arches  (alveolar  processes)  it  is  very  hard  and 
thick,  and  forms  the  external  part  of  the  gums.  Upon  the  latter, 
we  discover  neither  follicles  nor  villosities  ;  but  throughout  the 
rest  of  the  genial  region,  the  mucous  membrane  is  covered  with 
a  very  distinct  epithelium. 

x.  The  Skeleton. 

It  includes  that  portion  of  the  os  maxillare  inferius  which  is 
between  the  coronoid  process  and  the  mental  foramen,  as  well  as 
the  external  face  of  the  superior  and  inferior  dental  arches,  as  far 
as  the  dens  caninus.  It  should  be  noticed,  that,  when  the  inferior 

12 


IX)  OF    THE    HE /YD. 

maxillary  bone  is  fractured  in  this  region,  the  levator  muscles 
being  attached  to  the  posterior  fragment,  keep  it  applied  against 
the  upper  jaw.  The  anterior  fragment,  on  the  contrary,  is  liable 
to  be  drawn  downwards  by  the  depressors  which  originate  from 
the  os  hyoides. 

Sect.  7.  The  Mental  Region. 

This  region  is  bounded  on  each  side  by  the  preceding ;  superi- 
orly, by  the  inferior  labial  grove,  and  inferiorly,  by  the  supra-hyoi- 
deal  region.  It  forms  the  inferior  part  of  the  face,  and  makes  a 
projection,  which  varies  according  to  age,  sex,  embonpoint ;  age 
especially  :  in  the  middle  of  it,  and  inferiorly,  we  sometimes  ob- 
serve, during  the  elevation  of  the  lower  lip,  a  slight  depression  or 
dimple. 

CONSTITUENT  PARTS. 

i.  The  Skin. 

The  skin  is  much  thicker  than  that  of  the  preceding  regions, 
bearing  a  great  resemblance  to  that  of  the  cranium  ;  that  is  to 
say,  it  is  dense,  compact,  and  very  adherent  to  the  subjacent  tis- 
sues. It  contains  numerous  small  sebaceous  glands,  and  is  shad- 
ed with  an  abundance  of  hairs  in  man,  which  perforate  it  in  a 
perpendicular  direction,  constituting  the  beard.  When  the  cryp- 
tse  inflame,  they  give  rise  to  the  herpes  pustulosus  (dartre  puslu- 
leuse  (FAlibert)  of  the  chin  ;  when  the  sebaceous  matter  accumu- 
lates in  them,  it  produces  those  small,  red  and  painful  pimples, 
which  are  cured  by  puncturing  their  apex,  and  squeezing  out  a 
white  concrete  substance.  If  this  accumulation  takes  place  more 
slowly,  the  crypta3  become  much  larger,  forming  tannes. 

ii.  The  Cellular  Tissue. 

This  is  small  in  quantity,  and  does  not  form  subcutaneous  layers 
in  this  region  ;  it  is  blended  with  the  muscles,  and  is  merely  con- 
nected to  the  skin  by  very  short  and  very  close  filaments  ;  poste- 
riorly, between  the  muscles  and  bones  only,  there  is  a  certain 


OF    THE    HEAD.  91 

quantity  of  lamellated  tissue.  There  are  numerous  very  minute 
adipose  vesicles  here,  and  their  size  is  never  decidedly  augment- 
ed ;  so  that  the  embonpoint  of  the  chin,  strictly  so  called,  can 
scarcely  ever  vary.  It  is  in  the  cellular  tissue  nearest  to  the  skin, 
between  the  fleshy  fibres,  that  the  bulbs  of  the  hair  are  situated. 
The  compact  texture  of  the  cellular  element,  its  intimate  union 
with  the  skin,  and  the  very  great  density  of  the  latter  membrane, 
prevent  the  formation  of  abscesses  in  this  region,  and  cause  its 
inflammations  to  assume  the  erysipelatous  character. 

ni.  The  Muscles. 

Upon  the  sides  we  meet  with  a  small  portion  of  the  depressor 
anguli  oris,  the  fibres  of  which  ascend  obliquely  backwards ;  more 
anteriorly,  the  quadratus  genae,  the  internal  fibres  of  which  blend 
themselves  with  those  of  its  fellow  on  the  opposite  side ;  towards 
the  labial  region,  some  fibres  of  the  platysma,  which  are  intermin- 
gled with  those  of  the  preceding  and  cover  the  external  surface 
of  the  depressor  anguli ;  at  the  centre,  in  the  triangle  which  ex- 
ists between  the  quadrati,  the  superbus  (levator  menti).  This 
small  muscle  arises  by  two  fibrous  pedicles  from  the  two  fossettes 
which  are  situated  on  each  side  of  the  symphysis :  superiorly  and 
posteriorly,  it  is  invested  by  the  mucous  membrane ;  anteriorly, 
it  is  attached  to  the  skin,  and  slightly  covered  by  the  quadratus. 
As  its  fibres  are  perpendicular  to  the  axis  of  the  body,  it  must, 
in  contracting,  approximate  the  skin  to  the  jaw,  elevate  and  pro- 
trude the  lower  lip. 

iv.  The  Arteries. 

Between  the  bone,  the  mucous  lining  of  the  lip,  and  the  quad- 
ratus, we  find,  externally,  the  termination  of  the  inferior  dental 
(inf.  maxillary)  artery ;  inferiorly,  some  twigs  of  the  submental 
which  anastamose  superiorly  with  other  small  branches  from  the 
inferior  coronary ;  and  lastly,  some  twigs  which  originate  from 
the  facial,  below  the  giving  off  of  the  principal  artery  of  the 
lower  lip.  These  arteries,  however,  are  too  small  to  occasion 
troublesome  haemorrhage  when  the  mental  region  is  wounded. 
In  operations,  should  it  become  necessary  to  tie  them,  we  must 


1)  OF  THE    HEAD. 

expect  some  difficulties,  for  they  retract  within  the  muscles,  and 
as  they  are  enveloped  in  a  compact  cellular  tissue,  it  is  not  easy 
to  seize  them  with  the  forceps  :  therefore  in  such  cases  it  is  bet- 
ter to  use  the  tenaculum  or  compression. 

v.  The  Veins. 

They  accompany  the  arteries :  some  of  them  are  pretty  large 
and  subcutaneous,  and  descend  into  the  supra-hyoideal  region  in 
order  to  terminate  in  the  lingual  vein.  The  superficial  veins  ram- 
ify principally  in  the  skin ;  they  may  become  varicose,  giving  rise 
to  that  more  or  less  deep  red  colour  of  the  chin,  which  is  ob- 
served in  many  individuals. 

vi.  The  Lymphatics. 

Almost  all  of  these  vessels  pass  directly  to  the  submaxillary 
lymphatic  glands.  Hence  in  most  diseases  of  the  chin  these 
glandules  tumefy  with  the  greatest  facility. 

vii.   The  Nerves 

They  come  from  the  neck,  from  the  inferior  maxillary  bone, 
and  from  the  genial  region.  The  former  are  some  filaments 
from  the  nervus  mylo-hyoideus  and  from  the  submental  branch 
of  the  cervical  plexus ;  the  latter  are  twigs  derived  from  the  in- 
ferior branch  of  the  facial.  All  these  ramuscules  are  superficial. 
The  inferior  dental  nerve,  which  comes  out  through  the  mental 
foramen,  is  deep-seated,  and  is  distributed  to  the  muscles.  It  is 
so  situated  that  if  it  should  be  the  seat  of  neuralgia,  it  might  be 
easily  divided  and  without  danger.  For  this  purpose  an  incision 
should  be  made  within  the  lip,  on  a  level  with  the  canine  or  first 
molar  tooth,  when  the  nerve  will  be  found  some  lines  lower 
down,  in  contact  with  the  bone,  covered  by  some  larnellated  cel- 
lular tissue,  and  the  quadratus  muscle. 

viii.  The  Skeleton. 
This  consists  of  the  body  of  the  lower  jaw  simply,  and  pre 


OP   THE    HEAD.  93 

sents,  upon  the  median  line,  the  symphysis,  which  possesses  so  little 
solidity  in  the  child  that  the  two  osseous  pieces  may  be  separated 
in  consequence  of  external  violence, — a  blow,  for  example  ;  be- 
neath this  line,  a  small  triangular  surface,  which  is  covered  mere- 
ly by  the  skin ;  and  lastly,  the  mental  foramen,  quite  near  the 
limits  of  this  region,  opposite  the  first  molar  tooth :  hence  we  may 
amputate  a  great  portion  of  the  chin,  without  including  this  fora- 
men in  the  section ;  and  in  this  case,  the  principal  branch  of  the 
dental  nerve  will  not  be  divided,  so  that  the  pain  and  accidents 
consequent  thereto  will  be  avoided.  In  this  amputation,  we  are 
advised  to  saw  the  bone  in  such  a  manner  that  its  two  surfaces 
may  be  of  the  same  length,  that  is  to  say,  perpendicular  to  its 
direction ;  but  it  seems  to  us,  that  it  would  be  better  to  cut  them 
sloping,  at  the  expense  of  the  internal  surface,  because,  other- 
wise, the  curvature  would  not  permit  the  two  divided  ends  to 
touch  in  all  their  points,  if  we  wished  to  keep  them  in  contact. 
In  the  adult,  the  inferior  maxillary  bone  is  so  thick  in  this  region, 
that  its  direct  fractures  are  almost  impossible.  The  prominence 
which  it  forms  is  greatest  in  the  child,  on  account  of  the  absence 
of  the  teeth,  and  the  obtuseness  of  the  maxillary  angle.  In  old 
age,  it  again  becomes  more  prominent,  which  is  owing  to  the 
falling  out  of  the  teeth,  and  to  the  angle,  which  was  more  ap- 
proximated to  a  right  angle  in  the  adult,  again  becoming  round- 
ed off,  and  more  obtuse.  With  regard  to  its  periosteum,  there  is 
nothing  peculiar.  The  muscles  are  separated  from  it  by  a  cellu- 
lar tissue,  which  is  more  distinct  than  the  subcutaneous ;  hence 
its  inflammations  more  frequently  assume  the  phlegmonous  char- 
acter, and  as  the  buccal  mucous  membrane  is  all  that  intervenes 
between  it  and  the  mouth,  superiorly  and  posteriorly,  these  small 
abscesses  always  open  into  the  latter.  Furthermore,  as  all  the 
tissues  possess  less  density  in  this  direction  than  towards  the  skin, 
abscesses,  of  whatsoever  nature  they  may  be,  have  a  greater  ten- 
dency to  direct  their  course  internally  than  externally.  These 
collections  should  always  be  evacuted  from  within,  whereby  less 
pain  will  be  produced,  and  unsightly  scars  prevented. 

Sect.  8.  The  Labial  Region. 
This  region  comprehends  the  two  lips,  and  is  bounded,  supe- 


OF    THE    HEAD. 

riorly,  by  the  nose  and  the  naso-labial  furrow ;  inferiorly,  by  the 
mento-labial  groove  ;*  and,  laterally,  by  the  fossette  at  the  angle 
of  the  lips ;  hence  its  figure  is  elliptical. 

Superior  Lip. 

In  the  middle  of  its  external  aspect  we  observe  a  species  of 
groove  circumscribed  by  two  crests  which  descend  from  the  sep- 
tum of  the  nose  upon  the  free  border  of  the  lip.  According  to 
Blumenbach  and  some  modern  anatomists,  these  two  crests  would 
be  the  traces  of  the  cicatrization  of  the  three  portions  of  which 
this  lip  is  said  to  consist  in  the  early  stages  of  foetal  existence. 
According  to  this  idea,  also,  the  hare-lip  would  be  owing  to  the 
cicatrization  not  being  completed  on  one  side :  hence  this  con- 
genital division  would  never  exist  on  the  median  line,  and  if  the 
union  of  the  two  lateral  portions  with  the  median  should  fail  at 
the  same  time,  there  would  be  a  double  hare-lip.  The  free  bor- 
der of  this  lip  forms  a  gentle  curvature,  which  is  concave  infe- 
riorly, and  which  is  divided  into  two  upon  the  median  line  by  a 
gradual  elevation.  This  eminence  is  the  termination  of  that  por- 
tion of  the  lip  along  which  the  groove,  just  pointed  out  upon  its 
anterior  surface,  runs.  Since  this  disposition  enters  into  the  nor- 
mal conformation,  we  should  endeavour  to  re-establish  it  when 
we  perform  the  operation  for  hare-lip.  It  is  on  this  account  that 
we  are  recommended  to  make  the  first  needle  which  passes 
through  the  lip,  describe  the  arc  of  a  circle,  the  convexity  of 
which  looks  backwards  and  upwards. 

CONSTITUENT    PARTS. 

i.  The  Skin. 

It  supports  the  moustachios  in  the  adult  male ;  it  is  a  little 
thinner  than  that  of  the  chin,  and  becomes  more  intimately 
blended  with  the  subjacent  tissues,  in  proportion  as  it  approxi- 
mates the  free  border  of  the  lip.  It  also  becomes  thinner  as  it 
approaches  this  border,  and  suddenly  changes  its  character,  in 

*  According  to  the  physiognomical  doctrine  of  Dr.  Jadelot  this  furrow  constitutes 
'he  mental  feature,  and  is  concerned  in  affections  of  the  chest. 


OF    THE    HEAR.  95 

order  to  form  the  delicate  rosy  pellicle  which  covers  it,  and  which 
is  reflected  behind  the  lip  under  the  name  of  the  labial  mucous 
membrane.  The  hairs  which  we  observe  upon  it  perforate  it  in 
the  same  manner  as  those  on  the  chin.  It  also  contains  seba- 
ceous follicles,  which  are  subject  to  the  same  alterations  as  in  the 
preceding  region,  but  less  frequently. 

n.   The  Cellular  Tissue. 

Its  texture  is  so  delicate,  and  its  quantity  so  inconsiderable, 
that  it  can  scarcely  be  distinguished  from  the  other  elements, 
which  are  so  blended  together  in  the  lips  as  to  form  but  one 
homogeneous  mass.  The  adipose  vesicles  are  still  smaller  than 
in  the  mental  region. 

in.  The  Muscles. 

We  have  to  consider  especially  the  superior  half  of  the  orbicu- 
laris  oris.  Upon  the  middle  of  the  anterior  surface  of  this  mus- 
cle we  frequently  see  two  fasciculi,  which  ascend  perpendicularly 
towards  the  sides  of  the  nasal  septum,  and  which  correspond  to 
the  crests  observed  upon  the  surface.  These  are  the  nasales 
labii  superioris  (incisifs  supmeurs).  Behind  the  superior  half 
of  the  orbicularis  and  the  mucous  membrane,  upon  the  sides  of 
the  anterior  nasal  spine,  we  find  the  depressor  labii  superioris 
alaeque  nasi  (petit  myrtiforme)  close  to  the  bone.  The  convex 
border  of  the  former  receives,  from  the  median  line  towards  the 
sides,  the  terminations  of  the  levator  labii  superioris  alaeque  nasi, 
of  the  levator  proprius,  of  the  zygomaticus  minor,  of  the  levator 
anguli  oris,  of  the  zygomaticus  major  and  of  a  part  of  the  buccina- 
tor. The  union  of  the  orbicularis  with  the  mucous  membrane  is 
less  intimate  than  with  the  skin;  it  is  effected  by  means  of  a  thin 
layer  of  lamellated  cellular  tissue,  in  which  we  see  a  great  num- 
ber of  labial  glands.  The  mucous  membrane  itself  is  more  easy 
to  separate  from  the  muscle  in  proportion  as  it  approximates  its 
point  of  reflexion  upon  the  os  maxillare  ;  hence  abscesses  of  the 
lip  generally  give  way  at  this  point. 


DC  OF    THE    HEAD 


iv.  The  Arteries, 

In  the  first  place  we  find  the  superior  coronary  which  is  given 
off  by  the  facial  where  it  passes  through  the  fibres  of  the  ievator 
anguli  oris,  towards  the  external  extremity  of  the  naso-labial 
furrow.  This  coronary  is  placed  three  lines  above  the  free  bor- 
der of  the  lip,  in  the  posterior  plane  of  the  fleshy  fibres,  the  di- 
rection of  which  it  follows.  Previous  to  forming  its  arched  union 
with  its  similar  of  the  opposite  side,  it  gives  off  a  considerable 
branch  which  ascends  towards  the  septum.  A  transverse  in- 
cision, upon  the  median  line,  would  divide  these  ascending  arte- 
ries and  occasion  hoemorrhage  ;  whilst  a  wound  in  the  same  di- 
rection, but  a  little  further  outwards,  would  not  produce  it,  unless 
it  was  prolonged  as  far  as  the  naso-labial  furrow,  near  which  the 
facial  artery  also  runs.  The  arc  of  a  circle  which  the  two  su- 
perior coronaries  united  form,  gives  off  an  immense  quantity  of 
twigs  which  descend  or  ascend  parallel  to  each  other,  and  ter- 
minate for  the  most  part  in  the  labial  glands  and  mucous  mem- 
brane. These  are  the  twigs  which  constitute  that  beautiful  and 
complex  net-work  observed  in  the  latter  when  the  lip  is  everted. 
As  the  trunk  of  this  artery  is  almost  in  immediate  contact  with 
the  mucous  membrane,  we  may  readily  feel  its  pulsations  by  ap- 
plying the  finger  under  the  lip,  and  it  is  more  easily  wounded  in 
this  direction  than  from  the  surface.  The  artery  of  the  ala  nasi 
also  sometimes  gives  a  considerable  branch  to  the  upper  lip  ;  and 
not  unfrequently  the  facial  artery  dips  more  or  less  into  the  or- 
bicularis  muscle,  before  it  enters  the  interval  of  the  nasal  and 
zygomato-maxillary  regions. 

v.  The  Veins. 

They  are  still  la'rger  and  more  numerous  than  the  arteries,  and 
ramify  in  the  proper  tissue  of  the  lip,  where  they  occasionally 
become  varicose.  This  abundant  supply  of  vessels,  in  the  organ 
under  consideration,  accounts  for  the  frequency  with  which  erec- 
tile tumours  form  in  it,  and  for  the  active  species  of  tumefaction 
which  it  is  susceptible  of  in  the  normal  state.  This  remarkable 
vascularity,  together  with  the  intimate  commixture  of  the  differ* 


OF   THE   HEAD.  97 

cnt  elements  which  enter  into  the  composition  of  the  lips,  also 
explains  the  rapidity  with  which  they  tumefy,  and  the  great 
magnitude  which  they  acquire  in  acute  inflammations. 

vr.  The  Lymphatics. 

These  vessels  pass  through  the  genial  region  in  their  course  to 
the  submaxillary  lymphatic  glands. 

vii.  The  Nerves. 

The  superior  lip  is  freely  supplied  with  filaments  from  the 
sub-orbital,  the  buccinatorius  and  from  the  temporo-facial  branch 
of  the  seventh  pair.  These  nerves  are  sufficient  to  account  for 
the  exquisite  sensibility  of  this  lip  and  the  severe  pains  which 
accompany  its  acute  diseases. 

viii.  The  Skeleton. 

It  consists  of  the  anterior  surface  of  the  ossa  maxillaria  supe- 
riora  and  of  the  corresponding  dental  arch  as  far  as  the  dentes 
canini ;  consequently  we  find  in  it,  in  the  middle,  the  symphysis, 
surmounted  by  the  anterior  nasal  spine  ;  a  little  more  externally 
the  myrtiforme  fossette  (a  depression  for  the  depressor  alee  nasi)  ; 
then  the  undulating  line  of  the  alveolae  and  the  external  surface 
of  the  teeth.  It  is  in  this  region  that  the  superior  maxillary  bone 
presents  the  greatest  resistance ;  hence  the  infrequency  of  its 
fractures.  It  is  not  unusual  to  see  it  split  from  before  backwards, 
a  little  on  the  outer  side  of  the  median  line ;  and  sometimes  there 
is  a  similar  fissure  on  both  sides ;  a  disposition  which  is  frequently 
attendant  upon  the  simple  or  double  hare-lip.  The  middle  bone 
is  then  the  rudiment  of  the  os  incisivum  or  intermaxillare  of  mam- 
miferous  animals,  which,  by  anomaly  of  developement,  was  not 
united  to  those  between  which  it  is  locked  in  the  normal  state. 
Generally,  it  supports  the  first  two  incisor  teeth,  and  projects 
more  or  less  forwards.  In  adults,  especially  in  those  in  whom  the 
three  portions  of  the  lip  have  never  been  united,  it  passes  beyond 
the  line  of  the  maxillary  bones ;  and  this  appears  to  be  owing  to 
that  want  of  pressure  whirh  would  naturally  have  been  produced 

13 


98  OF    THE    HEAD. 

by  the  upper  lip  in  being  reflected  upon  the  bones.  The  mu~ 
cous  membrane  forms  a  duplicature  which  is  called  the  fraenum 
of  the  lip,  and  we  should  not  fail  to  divide  this  fold  before  we 
scarify  the  edges  of  the  fissure,  in  the  operation  for  hare-lip. 
Without  this  precaution,  it  would  interrupt  the  passage  of  the 
scissors,  so  that  the  posterior  blade  of  them  would  not  extend  as 
high  as  might  be  necessary.  So  with  respect  to  the  plate  which 
is  introduced  between  the  lip  and  the  bone,  when  the  bistoury  is 
employed.  It  is  at  the  groove  which  separates  the  posterior  sur- 
face of  the  superior  border  of  the  lip  from  the  bones,  thatDesault 
has  proposed  penetrating  into  the  maxillary  antrum.  In  fact 
nothing  is  more  simple :  all  that  is  necessary  is  to  detach  the 
mucous  membrane  between  the  root  of  the  canine  tooth  and  the 
obtuse  crest  which  descends  from  the  malar  eminence,  in  order 
to  arrive  at  it  by  penetrating  a  few  lines  higher  up.  In  the  same 
manner  we  might  reach  the  infra-orbital  nerve,  if  we  wished  to 
divide  it  by  the  mouth.  It  should  be  noticed,  however,  that  it 
would  be  difficult  to  avoid  dividing  the  caninus  muscle  (m.  lev. 
ang.  oris) ;  but  this  inconvenience  does  not  counterbalance  the 
advantages  obtained  by  preventing  the  formation  of  cicatrices 
on  the  skin,  in  women  especially.  The  posterior  surface  of  the 
superior  lip  being  concave,  it  is  necessary,  if  we  wish  to  avoid  a 
groove  behind  the  cicatrix  after  the  operation  for  the  hare-lip, 
that  the  needles  should  be  introduced  in  such  a  manner  that  they 
will  pass  through  the  raw  edges  of  the  wound  at  the  point  where 
the  two  anterior  thirds  of  their  thickness  unite  with  the  posterior 
third. 

Inferior  Lip. 

This  is  generally  a  little  thicker  than  the  preceding,  and  more- 
everted  forwards.  In  the  middle  of  its  free  border  we  observe  a 
depression,  into  which  the  superior  labial  crest  is  received,  and 
as  we  proceed  from  the  median  line  this  border  is  slightly  convex, 
its  extremities  being  turned  downwards.  From  this  normal  dis- 
position then,  it  follows  that  cancerous  tumours,  etc.,  may  be 
removed  by  a  semilunar  concave  flap ;  and  that  even  if  this  flap 
should  include  all  the  tissues  as  far  as  the  mento-labial  groove,  the 
notch  which  will  remain  after  cicatrization  will  not  be  so  great  as 


OP   THE    HEAD. 

we  might  have  expected.  In  fact  it  is  not  necessary  that  this  free 
border  should  be  convex  in  order  to  receive  the  lip  above.  Its 
natural  eversion  is  not  indispensable  to  its  functions,  for  which 
reason,  the  lip,  although  shorter  after  the  operation,  ascends  suffi- 
ciently to  touch  that  which  is  above  it ;  and,  furthermore,  the 
skin  of  the  neck  being  very  extensible,  as  the  cicatrix  forms  it 
draws  it  upwards,  and  thus  succeeds  in  elongating  the  lip.  A 
great  number  of  operations  performed  by  MM.  Dubois,  Richerand, 
Dupuytren,  etc.  confirm  these  assertions. 

The  anterior  surface  of  the  lower  lip  has  neither  vertical  crest 
nor  groove,  which  is  owing  to  its  being  formed  apparently  of  two 
lateral  portions  only.  Hence  if  congenital  hare-lip  should  be  met 
with  in  it,  it  ought  to  be  on  the  median  line. 

The  union  of  its  free  border  with  that  of  the  upper  lip,  consti- 
tutes the  labial  commissures.  These  commissures  are  occasion- 
ally the  seat  of  excoriations,  ulcers,  wounds,  etc.,  which  deserve 
strict  attention,  an  account  of  the  contractions  of  the  mouth  which 
they  might  occasion.  With  respect  to  wounds  which  extend 
from  one  of  these  commissures  externally,  they  must  necessarily 
be  brought  together  by  the  twisted  suture,  if  we  wish  to  prevent 
deformity.  Otherwise,  in  fact,  the  movements  of  the  lips  will 
prevent  cicatrization.  This  advice  is  equally  applicable  to  wounds 
of  the  eye-lids. 

Constituent  Parts. 

They  are  absolutely  the  same  with  those  of  the  upper  lip ;  it  is 
only  in  their  arrangement  that  any  difference  exists,  which  we 
will  now  point  out. 

i.  The  Skin. 

This  membrane  is  not  covered  by  so  great  a  quantity  of  hairs ; 
it  scarcely  supports  more  than  a  small  pencillous  cluster,  which  is 
placed  in  the  sub-labial  fossette, 

ir.  The  Adipo-cellular  Tissue. 

It  is  arranged  as  in  the  other  lip,  and  is  probably  a  little  more 
abundant. 


100 


OF   THE    HEAD, 


in.  The  Muscles. 

They  are  the  same  as  in  the  upper  lip,  unless  it  is  that  the  orbi- 
cularis  receives  upon  its  convex  border  the  extremity  of  the 
superbus,  of  the  quadratus  and  depressor  anguli  oris,  in  the  place 
of  those  which  enter  into  the  composition  of  the  superior. 

vi.  The  Arteries. 

They  are  a  little  different.  Thus  the  inferior  coronary  comes 
off  from  the  facial  at  a  more  considerable  distance  from  the  com- 
missure, and  the  arch  which  it  forms  with  its  fellow  does  not  give 
off  an  inferior  vertical  branch;  therefore  a  wound  across  the 
median  line  of  this  region  will  not  be  attended  with  hemorrhage  ; 
besides,  it  does  not  approximate  the  free  border  of  the  lip  so  much 
as  the  superior  coronary,  unless  it  is  in  the  middle.  From  this 
disposition  it  follows  that,  in  dividing  the  lip  from  above  down- 
wards, we  will  reach  the  artery  sooner  in  proportion  to  the  dis- 
tance of  the  incision  from  its  origin  In  order  to  ascertain  the 
exact  course  of  this  vessel,  it  is  sufficient  to  imagine  a  curve  passing 
about  three  lines  from  the  edge  of  the  lip  and  terminating  at  the 
anterior  and  inferior  part  of  the  masseter.  The  lower  lip  also 
receives  some  twigs  from  the  mental :  a  considerable  branch  is 
also  given  to  it  by  the  coronary  itself,  near  its  origin  from  the  facial. 

v.  The  Veins  and  Lymphatics. 

These  vessels  possess  the  same  characters  as  those  of  the  chin 
and  superior  lip. 

vi.  The  Nerves. 

Filaments  from  the  termination  of  the  inferior  dental,  and  some 
of  those  of  the  buccal  are  distributed  to  the  deep-seated  parts. 
The  superficial  twigs  are  derived  from  the  eervico-facial  branch 
of  the  respiratory  of  the  face,  and  also  from  the  ascending  branch- 
es of  the  cervical  plexus.  In  short,  the  lower  lip  is  less  freely 
supplied  with  nerves  than  the  superior,  and  its  sensibility  is  less 
acute. 


OF   THE   HEAB.  101 


vn.  The  Mucous  Membrane. 

It  likewise  forms  a  duplicature,  which  is  shorter  than  that  of 
the  upper  lip,  and  is  attached  to  the  maxillary  symphysis.  The 
labial  glands  which  separate  this  membrane  from  the  muscles  are 
more  numerous,  larger,  and  their  excretory  duct  more  distinct 
than  in  the  superior  lip. 

VHI.  The  Skeleton. 

It  comprises  the  anterior  portion  of  the  inferior  alveolar  arch, 
and  the  external  surface  of  the  dentes  incisivi  et  canini. 

Sect.  6.  T/ie  Olf active  Region.  (Vide  Plate  2.) 

It  is  composed  of  the  wlole  of  the  interior  of  the  nasal  fossa?. 
The  latter  are  limited,  superiorly,  by  the  anterior  third  of  the 
base  of  the  cranium  and  the  internal  surface  of  the  nose  properly 
so  called ;  inferiorly,  by  the  palatine  arch ;  externally,  by  the  zygo- 
matic  fossa,  the  orbit  and  the  maxillary  sinus  ;  posteriorly,  by  the 
pharynx,  and  anteriorly  by  the  opening  of  the  nose.  A  vertical 
septum  separates  them  from  each  other  throughout  their  whole  ex- 
tent ;  but  this  septum  frequently  inclines  more  to  one  side  than  the 
other ;  and  when  this  defect  of  symmetry  is  carried  very  far  it 
may  have  effect  over  the  sound  of  the  voice,  respiration,  and 
induce  the  belief  that  polypi  exist.  This  mistake  has  several 
times  occurred,  and  surgeons,  by  their  inconsiderate  manoeuvres, 
have  destroyed  the  septum  itself,  instead  of  tearing  out  these 
pretended  polypi.  We  have  seen  two  patients  consulting  Prof. 
Bougon  this  present  year,  in  whom  similar  attempts  had  been 
made.  In  both,  the  cartilaginous  portion  of  the  septum  touched 
the  inferior  turbinated  bone ;  and  in  one  of  them,  three  separate 
trials  had  been  made  to  extract  the  supposed  polypus,  and  so 
incautiously,  that  the  two  nasal  fossae  communicated  with  each 
other  through  an  opening  into  which  the  end  of  the  little  finger 
might  be  easily  introduced. 

As  the  nasal  cavities  are  very  complicated,  we  consider  it  best 
to  examine  them  in  their  different  parts :  thus,  we  will  shew  sue- 


1O2  OF    THE    HEAIJ. 

cessively  the  anterior  apertures,  the  vault,  the  floor,  the  internal 
and  external  parietes,  and  the  posterior  opening. 

i.  The  anterior  openings  of  the  Nostrils. 

They  look  more  or  less  directly  downwards,  according  to 
the  degree  of  elevation  or  depression  of  the  lobule  of  the 
nose.  Their  form  is  that  of  an  oval,  the  anterior  extremity 
of  which  is  the  smallest.  The  investing  mucous  membrane  is 
thick,  adherent,  slightly  coloured,  and  participates,  for  the  most 
part,  in  the  characters  of  the  skin ;  a  few  hairs  originate  from  it, 
which  serve  to  catch  foreign  atoms  which  might  be  introduced 
into  the  nostrils.  Their  skeleton  is  formed  by  the  cartilage  with 
a  double  branch,  which  was  pointed  out,  when  speaking  of  the 
extremity  of  the  nose,  in  the  nasal  region.  This  cartilage  is  en- 
closed, on  all  sides,  between  the  skin  and  the  mucous  membrane  ; 
the  posterior  extremity  of  its  internal  branch  does  not  touch  the 
anterior  nasal  spine ;  on  the  contrary,  this  extremity  turns  out- 
wards, and  tends  to  complete  the  circle  by  approximating  that  of 
the  external  branch,  which,  on  its  side,  is  inclined  inwards.  It 
results  from  this  arrangement  that  the  large  extremity  of  the 
anterior  opening  of  the  nose  is  actually  situated  in  the  upper 
lip,  lower  than  the  floor  of  the  nasal  fossae :  whence  it  follows  that, 
in  order  to  introduce  a  probe,  forceps,  the  finger,  or  any  foreign 
body  whatsoever  into  the  nose,  we  must  first  pass  it  obliquely 
upwards,  to  the  extent  of  several  lines,  before  we  give  it  the 
horizontal  direction ;  whence  it  follows  also,  that  it  is  necessary 
to  press  up  the  lobule  of  the  nose  considerably,  when  we  wish 
to  have  a  view  of  these  cavities. 

ii.  The  Vault. 

The  vault  is  the  longest  paries  of  the  nostrils,  and  may  be  di- 
vided into  three  portions :  the  anterior,  which  is  inclined  down- 
wards in  the  direction  of  the  dorsum  nasi,  to  which  it  corres- 
ponds. In  this  portion,  which  forms,  in  uniting  itself  writh  the 
septum,  a  groove  of  considerable  depth,  the  mucous  membrane 
is  delicate  and  villous,  but  does  not  enclose  many  follicles :  this 
membrane  is  less  adherent  here  than  in  the  opening  which  has 


OF   THE    HEAD.  103 

just  been  examined ;  polypi  seldom  originate  from  it ;  but  it  is 
frequently  the  seat  of  cancerous  or  sanious  ulcers  called  ozence. 
The  skeleton  which  enters  into  the  composition  of  this  part  of 
the  vault  of  the  nasal  fossa3,  is  formed,  from  above  downwards, 
by  a  small  portion  of  the  nasal  notch  of  the  os  frontis ;  by  the 
posterior  face  of  the  os  nasi  which  is  inclined  outwards  towards 
the  nasal  process  of  the  superior  maxillary  bone,  which  produces 
the  groove  pointed  out  above  ;  by  the  internal  surface  of  the  tri- 
angular cartilage,  and  of  that  of  the  free  extremity  of  the  nose. 
It  should  be  remarked  that  where  the  nasal  gutter  terminates 
under  the  latter,  there  is  a  species  of  cul-de-sac,  which  renders 
the  lobule  much  thinner  than  we  \vould  suppose  it  to  be  from 
an  external  examination  of  it  simply  :  therefore,  when  we  extir- 
pate or  cauterize  its  cancerous  excrescences,  we  must  avoid  pen- 
etrating too  deeply,  lest  we  occasion  an, opening  into  the  cavity 
of  the  nose,  which  would  remain  fistulous.  There  is  at  present  a 
case  of  this  kind  in  the  Hospital  of  la  Faculte,  in  a  woman 
seventy  years  of  age.  A  cancerous  ulcer  was  situated  on  the 
left  side  of  the  lobule  of  the  nose.  The  disorganised  structure 
was  extirpated  and  the  arsenical  paste  applied.  The  woman  was 
cured,  but  an  opening  remains  between  the  lobule  and  ala  nasi. 

It  is  between  the  ala  nasi  and  the  mucous  membrane  that  the 
vessels  and  nerves  coming  from  the  orbit  are  placed.  A  con 
siderable  branch  of  artery  and  of  vein  pass  through  the  bone  near 
its  middle,  in  their  way  to  the  lobule,  or  remain  upon  the  dorsum 
of  the  organ,  producing  habitual  redness  of  it  in  some  individu- 
als, from  the  varicose  state  of  the  capillaries  of  the  venous 
branch.  The  active  circulation  in  the  arterial  branch  also  ex- 
plains the  bright  colour  which  is  manifested  in  the  same  parts  du- 
ring the  process  of  certain  diseases ;  which  colour  generally 
indicates  an  epistaxis,  and  which  guided  Galen  in  forming  his 
celebrated  prognosis.  The  naso-lobar  nerve  is  imbedded  in  a 
small  furrow  which  conducts  it  to  the  inferior  border  of  the 
bone,  where  a  slight  notch  permits  it  to  pass  upon  the  external 
surface  of  the  cartilages. 

From  what  has  preceded  we  see  that  this  part  of  the  superior 
paries  is  very  solid,  and  so  constructed  that  it  opposes  great 
resistance  to  such  foreign  agents  as  would  tend  to  depress,  or 
fracture  it,  etc. 


104  OF    THE    HEAD. 

The  second,  or  middle  portion,  is  horizontal,  and  corresponds 
to  the  ethmoidal  fossa  of  the  cranium.  It  is  only  two  or  three 
lines  in  breadth.  The  mucous  membrane,  in  this  situation,  is 
thick,  soft  and  villous :  the  cribrated  lamina  of  the  ethmoid,  and, 
posteriorly,  a  very  small  portion  of  the  wings  of  Ingrassias  form 
the  skeleton  of  it.  As  these  osseous  plates  are  very  thin  and 
fragile,  foreign  bodies  driven  with  a  certain  force  into  the  nose, 
may  penetrate  the  cavity  of  the  cranium,  and  cause  instant  death 
by  lacerating  the  brain.  It  is  at  this  part  that  wounds  are  most 
dangerous ;  and  even  when  their  effects  do  not  extend  to  the 
cranial  box,  they  will  at  least  pervert  the  sense  of  smell,  by  the 
injury  which  they  inflict  upon  the  expansion  of  the  olfactory 
nerve  in  the  Schneiderian  membrane.  It  is  at  the  place  where 
this  portion  of  the  vault  unites  with  the  preceding  that  we  find, 
by  the  sides  of  the  crista  galli,  the  small  fissure  of  the  cribriform 
plate  which  gives  passage  to  the  ethmoidal  twig  of  the  ophthal- 
mic nerve  and  artery  from  the  cranium  into  the  nose. 

The  frequency  of  disease  in  this  portion  of  the  nostrils,  the 
tenuity  of  the  bones,  and  the  caries  with  which  they  are  some- 
times attacked  in  inveterate  cases  of  syphilis,  as  well  as  its  ana- 
tomical relations  with  the  cranium,  explain  in  what  manner  those 
herniae  of  the  brain,  of  which  M.  Boyer  has  spoken,  may  pene- 
trate into  the  cavity  of  the  nose. 

The  third,  or  most  remote  portion,  corresponds  to  the  Sella 
Turcica :  it  is  inclined  downwards  and  backwards.  The  mucous 
membrane  is  a  little  more  dense  at  this  point,  is  continuous  with 
that  of  the  vault  of  the  pharynx,  and  contains  some  follicles. 
The  skeleton  is  formed  by  a  prolongation  of  the  obitar  process 
of  the  os  palati,  the  superior  portion  of  the  vomer,  which,  to- 
gether with  the  body  of  the  sphenoid  bone,  constitutes  a  small 
canal,  through  which  the  pterygo-palatine  artery  and  nerve  run  ; 
more  anteriorly,  by  the  body  of  the  sphenoid  still,  and  the  (cor- 
nets) ossa  turbinata  of  Bertin.  Here  we  find  an  irregular  open- 
ing, which  varies  in  its  dimensions  and  leads  into  the  sinuses  of 
the  sphenoid.  If  we  could  readily  detect  the  diseases  of  these 
sinuses,  we  might  easily  penetrate  into  them,  as  we  shall  see, 
when  we  come  to  speak  of  the  external  paries.  We  are  induced 
to  believe,  for  several  reasons,  that  the  disagreeable  odour  which 
exhales  from  certain  individuals,  is  owing  to  ulceration  of  the 


OF    THE    HEAD.  105 

membrane  which  lines  these  cavities,  the  capacity  of  which 
varies,  and  which,  all  other  things  being  equal,  is  augmented  in 
proportion  to  the  advancement  of  age.  It  is  generally  in  this 
part  of  the  vault  that  the  force  of  blows  received  upon  the  ver- 
tex of  the  head  are  concentrated  ;  but  as  the  bone  is  spongy  and 
very  thick  it  is  rarely  fractured. 

in.  The  Internal  Parietes. 

They  are  formed  by  the  faces  of  the  septum.  The  pituitary 
membrane  which  covers  it  is  very  thick,  vascular,  and  lined  by  a 
very  strong  fibrous  lamina,  which  also  exists  throughout  the  whole 
extent  of  the  nasal  fossae ;  but  is  in  no  part  so  distinct  as  it  is  in 
this.  Although  this  species  of  periosteum  is  pretty  firmly  ad- 
herent to  the  septum,  yet  it  is  less  so  than  to  the  mucous  tunic. 
In  addition  to  the  internal  nervous  branches  of  the  first  paries, 
which  are  distributed  between  these  two  laminae,  we  also  find 
the  naso-palatine  nerve  similarly  interposed.  The  septum  is 
formed  by  the  whole  of  the  vomer ;  more  anteriorly  and  supe- 
riorly, by  the  perpendicular  plate  of  the  ethmoid ;  and  quite  an- 
teriorly, by  the  cartilage  of  the  septum.  To  these  we  must  also 
add  superiorly  the  crest  of  the  sphenoid,  which  is  embraced  by 
the  separation  of  the  plates  of  the  vomer;  the  nasal  spine  of  the 
os  frontis  resting  upon  the  ethmoidal  plate,  and,  inferiorly,  the 
species  of  crest  which  exists  at  the  junction  of  the  superior  max- 
illary and  palate  bones  with  each  other.  The  two  nasal  spines 
form  the  anterior  and  posterior  extremities  of  the  inferior  border 
of  the  septum.  As  all  these  parts  are  thin  and  fragile,  the  intro- 
duction of  the  finger  or  instruments  into  the  nose  requires  great 
caution,  in  order  to  avoid  making  a  communication  between  the 
two  nasal  cavities,  which  would  occasion  more  or  less  derange- 
ment in  the  sense  of  smell  and  the  sound  of  the  voice.  The 
pressure  of  polypi  upon  this  septum  may  also  produce  a  perfora- 
tion of  it ;  and  we  have  seen  several  examples  in  which  this  state 
of  parts  was  congenital. 

iv.  The  Inferior  Fames  or  Floor. 

This  paries  is  formed  by  the  superior  surface  of  the  palatino 

14 


100 


OF    THE    HEAD. 


arch,  and  is  about  two  inches  in  length,  or  three,  if  prolonged  to 
the  apex  of  the  nose.  It  is  regularly  concave  in  its  transverse 
direction ;  plane  from  before  backwards,  and  gently  inclined 
towards  the  pharynx  ;  its  anterior  border  is  raised  a  little,  which 
should  be  remembered  when  we  wish  to  probe  the  nasal  canal. 

Its  schneiderian  membrane  possesses  the  same  characters  as 
upon  the  septum ;  but  it  receives  a  much  smaller  quantity  of 
nerves,  and  is  rarely  the  seat  of  polypi :  syphilitic  and  cancerous 
ulcers,  however,  are  frequently  observed  in  it. 

The  palatine  process  of  the  superior  maxillary  bone,  and  the 
horizontal  portion  of  the  os  palati,  constitute  the  skeleton  of  this 
paries ;  consequently,  we  see  upon  it  a  transverse  suture  which 
unites  these  two  bones  ;  and  sometimes  there  is  a  second,  ante- 
riorly, which  indicates  the  persistance  of  the  os  intermaxillare. 
The  latter  has  been  observed  in  man  by  Vesalius,*  Columbus,f 
etc ,  and  more  recently  by  M.  Lobstein.  It  is  the  separation 
of  this  anormal  suture  which  so  frequently  co-exists  with  the 
double  or  single  hare  lip ;  between  it,  or  the  situation  which  it 
occupies  when  it  does  exist,  and  the  septum,  close  to  the  anterior 
border,  we  observe  the  nasal  aperture  of  the  naso-palatine^ 
canal,  through  which  the  naso-palatine  nerve  passes,  in  order  to 
enter  the  ganglion  of  the  same  name.  This  aperture  is  closed 
by  the  mucous  membrane,  and  can  only  be  seen  upon  the  de- 
nuded bones. 


v. 


The  External  Paries, 


This  is  the  most  complicated  and  most  important.  Inferiorly, 
it  is  quite  as  extensive  as  the  preceding,  longer  in  the  middle  of 
its  height,  and  shorter  at  its  most  superior  part.  The  mucous 
membrane  which  appertains  to  it  is  thicker,  redder,  and  more 
vascular  than  elsewhere ;  only  it  becomes  more  delicate  and 
attenuated  where  it  penetrates  the  accessory  cavities,  or  rather 
its  fibrous  lining  then  abandons  it.  Upon  the  free  border  of 
each  turbinated  bone,  it  forms  a  fold  which  seems  to  give  to 
these  shells  greater  breadth,  and  prolongs  them  further  anteriorly 
and  posteriorly.  It  adheres  very  firmly  to  the  skeleton  ;  and,  as 
it  is  abundantly  supplied  with  vessels,  but  a  very  slight  conges- 

*  De  Fabric :  corporis  humani,  etc.  t  De  re  anatomic^,  etc.  lib.  ler. 


OF   THE    HEAD.  107 

t  ion  is  necessary  to  produce  epistaxis :  hence  the  frequency  of 
this  haemorrhage.  The  irregularities  of  the  surfaces  which  it  is 
obliged  to  cover,  are  probably  the  principal  cause  of  the  en- 
gorgements, tumours,  and  diseases  of  different  natures  which  so 
frequently  occur  in  it.  We  should  be  upon  our  guard  against 
the  bulging  out  of  the  folds  which  it  forms  upon  the  borders  of 
the  ossa  turbinata,  because  they  have  more  than  once  been  mis- 
taken for  polypi,  and  wrenched  out  as  such ;  more  than  once, 
also,  they  have  been  torn  in  seeking  for  these  excrescences  which 
did  not  exist,  and  unreflecting  surgeons  have  mistaken  the  flaps, 
thus  violently  formed,  for  portions  of  these  tumours  which  they 
have  been  determined  to  find.  This  membrane  also  diminishes 
the  greater  proportion  of  those  apertures  which  we  are  about  to 
examine  ;  but  in  no  part  of  it  do  fleshy  fibres  exist. 

In  the  summit  of,  and  little  towards  the  posterior  part  of  this 
paries,  we  find  a  short  and  shallow  groove,  which  is  separated 
from  the  vault  by  a  small  crest,  into  which  enters  what  Gavard 
calls  the  square  plate  of  the  ethmoid.  This  groove  does  not  lead 
to  any  important  cavity.  More  inferiorly,  we  see  the  superior 
turbinated  bone  of  Morgagni,  which  terminates,  anteriorly,  to- 
wards the  middle  of  the  length  of  the  paries.  The  gutter  which 
this  bone  circumscribes  is  broader  and  more  superficial  at  its 
posterior  than  at  its  anterior  part.  In  the  first  direction  it  leads 
to  two  openings ;  a  superior,  which  communicates  with  the  pos- 
terior ethmoidal  cells  and  the  sphenoidal  sinus,  into  which  we 
might  easily  penetrate  by  passing  a  stylet  above  the  middle  turbi- 
nated bone,  along  the  external  paries  of  the  superior  meatus,  pro- 
vided that,  when  the  extremity  of  the  instrument  gets  near  the 
termination  of  this  gutter,  we  elevate  it  a  little  as  we  pass  it 
backwards.  The  other  is  inferior  and  situated  upon  the  external 
paries :  it  leads  directly  into  the  pterygo-maxillary  and  zygomatic 
fossae.  Through  this  opening,  the  spheno-palatine  vessels  and 
nerves  enter  the  nose.  Polypi  may  also  pass  from  the  nasal  fossae 
through  this  aperture  into  the  zygomatic  fossa,  and  be  prolonged 
into  the  substance  of  the  cheek  anterior  to  the  masseter.  In 
1824,  we  saw  a  remarkable  example  of  this  kind  in  a  young 
man  aetat.  20,  who  continued  a  long  time  in  the  hospital  of  the 
Ecole  de  Medecine.  This  opening  is  situated  just  below  the 
posterior  extremity  of  the  superior  turbinated  bone,  and  a  probe, 


108  OF   THE    HEAD. 

having  its  extremity  slightly  curved,  might  be  easily  introduced 
into  it :  anteriorly,  the  meatus  terminates  upon  a  plane  surface, 
which  presents  nothing  remarkable. 

Below  this,  we  find  the  ethmoidal  or  middle  turbinated  bone, 
which  is  prolonged  in  a  pointed  form  near  to  the  pharyngeal 
opening  of  the  nostrils ;  the  anterior  extremity  of  this  bone  is 
raised  a  little,  and  terminates  four  or  five  lines  from  the  os  nasi. 
Hence  it  follows  that  it  is  more  prominent,  and  consequently  that 
the  middle  meatus  is  deeper  in  the  centre  than  towards  its  two 
extremities.  This  meatus  is  much  wider  anteriorly  than  poste- 
riorly. In  it  we  meet  with  two  openings  which  are  worthy  of 
attention  ;  one  of  which  is  higher  than  the  other,  and  is  situated 
under  the  anterior  extremity  of  this  turbinated  bone  ;  a  small  ex- 
cavation leads  to  it  from  behind  forwards,  from  below  upwards, 
and  from  within  outwards :  this  is  the  inferior  orifice  of  the  ante- 
rior ethmoidal  cells,  or  of  the  Infundibulum  by  which  we  pene- 
trate into  the  frontal  sinus.  It  is  by  this  communication  that 
wTorms,  etc.  have  made  their  way  from  the  nose  into  the  frontal 
sinus,  deceiving  some  persons  with  respect  to  their  real  origin. 
It  is  the  cause  why  wounds  of  the  frontal  sinus  with  loss  of  sub- 
stance generally  remain  fistulous  ;  it  enables  morbid  fluids  secreted 
in  the  nose  to  pass  between  the  plates  of  the  os  frontis,  and,  on 
the  other  hand,  polypi,  pus,  etc.,  to  descend  from  the  sinus  into 
the  nasal  fossae.  It  would  also  be  possible  to  throw  up  injections 
through  this  opening,  if  they  should  be  deemed  useful. 

The  other  aperture  is  situated  towards  the  middle  of  the  length 
of  the  meatus,  a  little  higher  than  the  inferior  border  of  the  tur- 
binated bone,  about  an  inch  and  a  half  from  the  anterior  nasal 
opening.  In  this  place  the  nasal  gutter  is  excavated,  on  which 
account  the  aperture  in  question  looks  slightly  downwards  and 
inwards :  so  that,  if  we  wish  to  pass  an  instrument  into  it,  we 
must  direct  it  from  below  upwards  and  from  within  outwards. 
In  the  dead  subject  this  little  operation  is,  in  this  way,  very 
easy  to  perform.  But,  if  the  instrument  is  at  first  carried  too 
high  or  too  far  back,  we  will  meet  with  many  difficulties,  and  it  is 
doubtless  owing  to  this  circumstance  that  surgeons  have  aban- 
doned this  operation,  so  highly  recommended  by  Jourdin  and 
Alouelle.  The  mucous  membrane  which  covers  the  border  of 
i  his  opening  is  thick,  and  forms  a  circular  fold,  in  which  there  are 


OF   THE    HEAD.  109 

a.  great  number  of  large  follicles,  considered  by  some  anatomists 
as  one  gland.  This  fold,  like  those  which  envelope  the  loose  mar- 
gins of  the  turbinated  bones,  is  susceptible  of  becoming  turgid, 
and  thereby  closing  the  entrance  into  the  anti-urn  of  Hygmore ; 
but  it  does  not  form  either  a  valve,  or  sphincter  which  might  ob- 
struct the  passage  into  this  cavity.  The  antrum  Highmorianum, 
or  maxillary  sinus,  is  a  very  important  part  of  the  face  ;  its  figure 
is  pyramidal ;  its  superior  paries  forms  the  floor  of  the  orbit,  and  it 
is  in  this  wall  that  we  find  the  infra-orbital  vessels  and  nerve.  The 
anterior  paries  corresponds  to  the  canine  fossa,  and  includes  the 
anterior  and  superior  dental  nerves  of  the  infra-orbital  branch : 
the  rupture,  laceration  or  any  lesion  whatsoever  of  these  nerves 
may,  to  a  certain  extent,  explain  the  very  serious  symptoms  which 
sometimes  follow  the  extraction  of  the  dens  canina.  We  have 
noticed  that  Desault  perforated  this  wall  in  order  to  expose  the 
sinus. 

The  inferior  paries  rests  upon  the  alveoli  of  the  molar  teeth,  and 
is  sometimes  perforated  by  the  root  of  these  organs.  The  third 
or  fourth  molar  tooth  approximates  nearest  to  the  maxillary  cavity, 
and  it  is  by  their  alveoli  that  we  prefer  perforating  this  cavity ; 
especially,  as  by  this  means,  the  artificial  opening  will  correspond 
to  the  most  dependent  point,  and  will  thereby  favour  the  escape 
of  pus,  or  any  other  foreign  body  which  we  may  desire  to  extract. 
It  is  also  in  consequence  of  the  relations  of  the  molares  with  the 
antrum  Highmoranium  that  fistulas  semetimes  follow  the  extrac- 
tion of  these  teeth.  The  posterior  paries  is  rounded  and  con- 
cave ;  it  encloses  the  nervous  filaments  which  pass  to  the  roots  of 
the  molar  teeth,  and  corresponds  to  the  zygomatic  fossa ;  the 
summit  is  prolonged  into  the  malar  eminence,  and  is  there  so  near 
the  surface  that  some  surgeons  have  considered  it  the  best  place 
for  applying  the  trephine,  and  Lamorier,  among  others,  advised 
perforating  the  maxillary  sinus  below  the  os  malse.  The  base  is 
the  largest  paries  of  this  cavity,  and  corresponds  to  the  whole  ex- 
tent of  the  middle  meatus ;  it  is  perforated  in  its  centre  by  the 
aperture  just  spoken  of,  a  little  nearer  its  superior  part,  however, 
than  its  inferior.  From  this  arrangement  we  may  comprehend 
why  pus,  or  other  fluids  accumulated  in  the  sinus,  will  escape  more 
readily  through  an  artificial  opening  in  the  alveoli  or  lower  part  of 


110  OF    THE    HE  A  It. 

the  canine  fossa,  than  by  the  natural  aperture  which  exists  in  the 
nose. 

Besides  these,  the  middle  meatus  presents  nothing  remarkable 
except  at  its  posterior  part,  where  it  leads  to  the  Eustachian  tube. 

Next  to  this  meatus  is  the  inferior,  or  maxillary  turbinated  bone, 
which  is  the  largest  and  longest,  terminating  in  an  elongated  point 
where  it  approximates  the  pharyngeal  opening,  and  in  a  fold 
slightly  inclined  downwards  towards  the  facial  aperture  of  the 
nostrils.  The  free  margin  of  this  bone  is  sometimes  three,  four, 
and  even  five  lines  from  the  floor  and  external  paries  of  the  nasal 
fossae ;  at  other  times,  on  the  contrary,  it  lies  so  close  to  them, 
that  "the  inferior  meatus  is  converted  into  a  complete  canal.  We 
also  find  all  the  intermediate  degrees,  whence  arises  the  various 
results  obtained  by  different  surgeons,  in  their  attempts  to  pene- 
trate into  the  nasal  duct,  as  recommended  by  BiancJii,  Laforest, 
etc.  Nevertheless,  this  operation  does  not  seem  to  deserve  that 
oblivion  into  which  it  has  fallen,  and  as  some  surgeons  of  celeb- 
rity, among  whom  is  M.  Gcnsoul,  of  Lyons,  are  again  attempting 
to  bring  it  into  vogue,  by  advising  us  to  act  upon  the  nasal  duct, 
in  cases  of  tumour  or  fistula  lachrymalis,  in  the  same  manner  as 
we  operate  upon  the  canal  of  the  urethra,  in  cases  of  stricture, 
according  to  the  method  of  Ducamp  ;  we  think  that  we  must 
devote  a  few  moments  to  the  investigation  of  the  anatomical  dis- 
position of  the  inferior  meatus.  It  is  a  gutter,  forming  the  three 
fourths  of  a  canal,  w^hich  corresponds  externally,  and  from  be- 
hind forwards,  to  the  vertical  portion  of  the  os  palati,  to  the  inter- 
nal surface  of  the  nasal  portion  of  the  superior  maxillary  bone  ; 
that  is  to  say,  to  the  inferior  fourth  of  the  base  of  the  maxillary 
sinus  ;  and  lastly  to  the  inferior  groove  of  the  ascending  process  of 
the  maxillary  bone.  Superiorly,  it  is  formed  by  the  concave  sur- 
face of  the  inferior  turbinated  bone,  and  inferiorly,  by  the  external 
part  of  the  floor  of  the  nasal  fossae.  The  nasal  duct  opens  into 
this  meatus  at  the  junction  of  its  external  and  internal  parietes, 
but  in  such  a  manner,  that  it  extends  a  line  and  a  half  further  upon 
this  latter ;  i.  e.  it  is  cut  obliquely  at  the  expense  of  the  turbinatc. 
and  looks  inwards,  and  a  little  backwards ;  hence  it  follows,  that 
we  must  also  give  this  direction  to  the  slope  of  the  canula,  when 
we  operate  for  fistula  lachrymalis  according  to  the  method  of 
Foubert :  and  in  the  same  manner,  when  we  introduce  the  probe. 


OF   THE   HEAD.  Ill 

we  must  elevate  its  extremity  from  behind  forwartls,  and  from 
within  outwards.  The  orifice  of  this  canal  is  situated  about  six 
lines  from  the  nasal  aperture,  and  we  do  not  think  that  this  dis- 
tance is  so  variable  as  Morgagni,  and  some  others  since  his  time, 
have  asserted.  In  fact,  in  one  hundred  heads,  M.  Vesigne*  found 
but  very  trifling  variations  ;  and  from  what  has  come  under  our 
own  observation,  these  differences  are  so  slight,  that  they  could 
not  prevent  the  easy  introduction  of  an  instrument  into  the  nasal 
duct.  It  is  bounded  anteriorly  by  a  prominence  which  is  formed 
by  the  posterior  margin  of  the  base  of  the  ascending  process ; 
superiorly,  under  the  inferior  turbinate,  this  prominence  is  sepa- 
rated from  the  orifice  of  the  nasal  canal  by  a  species  of  cul-de- 
sac,  into  which  the  probe  may  be  insinuated,  and  thereby  occasion 
the  principal  obstacle  to  its  introduction.  Another  cause  of  diffi- 
culty arises  from  the  instrument  not  being  sufficiently  curved  :  in 
fact,  it  is  necessary  to  bend  its  extremity  at  more  than  a  right  an- 
gle with  the  handle  ;  unless  this  is  done,  it  will  strike  against  the 
posterior  paries  of  the  duct,  and  penetrate  the  maxillary  sinus, 
if  much  force  is  exerted.  The  reason  of  this  peculiarity  is  found 
in  the  direction  of  the  duct  itself,  which  runs  obliquely  upwards, 
forwards,  and  very  slightly  outwards,  and  especially  in  the  mem- 
brane which  contracts  this  aperture.  This  fold  is  so  disposed, 
that  the  orifice  by  which  it  ascends  into  the  canal,  is  nearer  the 
posterior  than  the  anterior  semi-circle  of  this  osseous  canal. 

In  short,  we  think  that  it  would  generally  be  easy,  by  recollect- 
ing the  anatomical  peculiarities  which  have  just  been  detailed, 
together  with  a  little  habit,  to  introduce  into  the  nasal  canal,  by 
the  inferior  meatus,  probes,  bougies,  stylets,  with  the  view  of 
throwing  injections  into  it,  removing  its  obstructions,  cauterising 
it,  etc. 

It  is  also  by  the  inferior  meatus,  that  a  probe  may  be  passed 
from  the  nose  to  the  pharynx,  in  order  to  introduce  it  into  the 
Eustachian  tube  ;  but  we  must  then  be  careful  not  to  elevate  the 
instrument  too  much,  as  it  would  be  liable  to  fracture  the  turbi- 
nated  bone.  It  is  with  the  view  of  avoiding  this  inconvenience, 
that,  in  attempting  to  apply  a  ligature  around  polypi,  or  plugging 
the  nasal  fossae,  it  is  much  better  to  pass  the  instruments  upon  the 

,  1824. 


w  OP    THE    HEAD. 

inferior  paries,  between  the  floor  and  os  spongiosum,  than  to  slide 
them  along  the  meatus  itself. 

The  bones  which  enter  into  the  composition  of  the  external 
wall  of  the  nasal  cavities,  are  remarkable  only  for  their  greater  or 
less  degree  of  fragility.  Thus,  posteriorly,  the  skeleton  is  pretty 
solid,  because  it  is  formed  by  the  internal  surface  of  the  pterygoid 
process  and  the  posterior  parts  of  the  superior  maxillary  bones, 
upon  which  the  vertical  portion  of  the  ossa  palati  rest.  In  the 
middle  part,  it  is  extremely  brittle,  because  it  there  consists  only 
of  the  thin  plates  of  the  ethmoid  and  the  internal  paries  of  the 
nasal  sinus,  which  are  very  slender  and  very  fragile.  Therefore, 
operations  performed  in  this  point,  almost  always  occasion  the 
destruction  of  these  osseous  laminae.  Anteriorly,  the  solidity  is 
considerable,  as  it  is  there  constituted  by  the  nasal  process  of  the 
superior  maxillary  bone.  It  is  proper  to  remark,  before  conclud- 
ing, that  if  this  fragility  of  the  bones  has  its  inconveniences  in 
most  cases,  there  are,  nevertheless,  some;  in  which  it  may  prove 
advantageous.  For  example,  it  is  on  account  of  the  tenuity  of 
the  os  unguis,  that  we  are  advised  to  establish  through  it  an  arti- 
ficial course  for  the  tears,  either  by  following  the  method  of  Wol- 
house,  or  by  adopting  that  of  Hunter,  of  Scarpa,  etc.  We  know 
that  the  object  of  all  these  operations  is  to  cause  the  nasal  canal 
to  communicate  with  the  inferior  part  of  the  middle  meatus,  and 
that  Hunter  recommended  the  application  of  a  plate  of  ebony 
between  the  superior  and  middle  ossa  turbinata,  in  order  to  serve 
as  a  point  of  support  for  his  perforator.  With  respect  to  this 
plate,  the  disposition  of  the  parts  is  such  that  we  do  not  think 
that  it  would  be  impossible  to  make  use  of  it,  if  we  wished  to 
resort  to  the  method  of  the  English  surgeon.  At  least,  we  think- 
that  this  question  requires  still  further  examination. 

vi.  The  posterior  opening  of  the  Nasal  Fossa. 

This  opening  is  double,  and  formed  by  the  termination  of  the 
four  parietes.  Its  figure  is  that  of  an  oblong  square  placed  verti- 
cally ;  it  is  a  little  broader  below  than  above ;  its  perpendicular 
diameter  measures  about  an  inch  ;  its  transverse  inferior  diame- 
ter only  six  lines.  These  diameters  should  be  kept  in  mind  when 
we  are  obliged  to  introduce  the  finger,  plugs,  etc.,  from  the  pha- 


OP    THE    HEAD.  Ho 

rynx  into  the  nose,  in  order  that  the  greatest  breadth  of  the  for- 
eign bodies  may  correspond  with  the  greatest  diameters  of  the 
openings  through  which  they  are  to  be  passed. 

A  few  observations  remain  to  be  made  upon  the  vessels  and 
nerves  of  the  nostrils. 


A.  The  Arteries. 

They  come  from  the  internal  maxillary,  through  the  pterygo- 
palatine  foramen ;  from  the  ethmoidal  twigs  of  the  opthalmic  ; 
from  the  coronary  of  the  facial,  etc.  They  are  quite  small,  and 
of  very  little  surgical  importance  ;  but  where  they  ramify  in  the 
mucous  membrane,  they  become  very  superficial,  which  disposes 
them  to  hosmorrhage. 

B.  The  Veins. 

One  collateral  vein  accompanies  each  artery,  which  it  surpasses 
in  volume  ;  but  there  is  an  additional  one  which  communicates 
with  the  apex  of  the  longitudinal  sinus  by  the  foramen  coacum, 
and  others  which  pass  into  the  coronary  sinus,  through  the  pores 
of  the  sphenoid,  etc.  Vicq.  d'Azyr  thought  that  the  latter  might 
explain  the  active  hoemorrhages  which  occur  in  cerebral  diseases. 
These  small  veins  always  connect  the  circulation  of  the  nasal 
fossae  with  that  of  the  encephalon. 

C.  The  Lymphatics. 
They  have  not  been  satisfactorily  traced. 

D.  The  Nerves. 

These  organs  proceed  from  the  first  pair  which  is  entirely  dis- 
tributed to  this  region ;  also  from  the  fifth  which  gives  numerous 
branches  to  it  from  the  spheno-palatine  ganglion,  ophthalmic 
branch,  etc.  According  to  the  recent  experiments  of  M agendie, 
the  filaments  of  the  first  preside  over  the  sense  of  smell ;  those  of 
the  fifth,  on  the  contrary,  over  the  general  sensibility. 

15 


114  Ol    THE 


Sect.  10.  Buccal  Cavity  or  Region.  (See  plate  2.) 

It  is  circumscribed  anteriorly  and  laterally  by  the  internal  sur- 
face of  the  two  alveolar  arches  ;  posteriorly,  by  the  pharynx ;  su- 
periorly, by  the  nasal  fossae,  and  inferiorly  by  the  plane  of  the 
border  of  the  lower  jaw.  It  forms  a  cavity  which  is  naturally  fil- 
led by  the  tongue,  when  the  jaws  are  in  contact.  If  we  consider 
the  tongue  as  removed,  this  cavity  is  from  eighteen  to  twenty-one 
lines  in  height  in  the  middle,  and  a  few  lines  less  anteriorly  and 
posteriorly.  We  will  now  examine  it  successively  superiorly, 
laterally,  inferiorly  and  posteriorly. 

The  Palatine  Vault. 

This  part  forms  the  superior  paries,  and  is  inclined  upon  the 
sides  and  anteriorly,  becoming  continuous  with  the  dental  arches : 
it  is  very  concave  and  continuous  posteriorly  with  the  velum 
palati. 

CONSTITUENT   PARTS. 

i.  The  Mucous  Membrane. 

The  mucous  tissue  is  dense,  compact,  slightly  coloured,  non- 
villous  and  presents  many  very  hard  transverse  wrinkles,  espe- 
cially anteriorly,  but  becomes  softer  and  of  a  redder  colour  poste- 
riorly. It  is  covered  by  a  very  distinct  epithelium,  which  is  elevated 
in  a  considerable  number  of  diseases.  In  consequence  of  th<^ 
compact  texture  of  this  membrane  it  is  but  seldom  diseased. 

n.  The  Sub-mucous  Tissue. 

This  is  a  very  strong  and  almost  inextensible  fibro-cellukn 
lamina,  which  answers  the  purpose  of  a  periosteum  to  the  bones, 
and  of  a  lamellated  envelope  to  the  mucous  membrane  ;  that  is  to 
say,  that  its  superficial  surface  is  filamentous  and  less  compact 
than  its  deep  surface.  The  cryptae  are  situated  upon  the  former 
of  these  surfaces,  between  it  and  the  mucous  membrane.  This 
tissue  sometimes  gives  origin  to  extremely  hard  fibrous  bodies. 


OF   THE    HEAD.  115 

which  seldom  acquire,  however,  a  large  volume.     It  adheres 
very  firmly  to  the  bones,  especially  at  the  sutures. 

in.  The  Arteries. 

They  enter  this  region  through  the  posterior  palatine  foramina ; 
their  principal  branch  follows  the  contour  of  the  vault,  first  be- 
tween the  fibrous  tissue  and  the  bones,  then  between  the  fibrous 
and  mucous  membranes.  If  one  of  these  branches  should  be- 
come aneurismatic,  an  example  of  which  has  been  observed  by 
M.  Delabarre,  it  would  be  very  difficult  to  treat  the  disease 
otherwise  than  by  the  actual  cautery ;  for  the  inequality  of  the 
bones  and  the  firmness  of  the  parts  would  oppose  the  application 
of  compression  or  the  ligature. 

iv.  The  Veins. 
They  have  the  same  arrangement  as  the  arteries. 

v.  The  Lymphatics. 

Our  knowledge  of  them  is  imperfect,  but  they  present  nothing 
remarkable. 

vi.  The  Nerves. 

They  all  come  from  the  spheno-palatine  ganglion,  but  by  two 
different  routes ;  first,  the  superior  palatine  nerve  which  descends 
along  the  canal  of  this  name  in  order  to  meet  with  the  artery,  and 
follows  its  course  into  the  palatine  vault :  next,  the  naso-palatine, 
which  goes  to  form  the  ganglion  of  the  same  name  in  the  anterior 
palatine  foramen.  This  ganglion,  discovered  by  MM.  Jacobson 
and  H.  Cloquet,  afterwards  gives  off  a  pencil  of  filaments  which 
are  distributed  to  the  palatine  membrane  behind  the  incisores 
teeth. 

vii.  The  Skeleton. 
We  find  in  it  the  palatine  process  of  the  superior  maxillary 


116  OF    THE    HEAD. 

bone  and  the  horizontal  portion  of  the  os  palati.  These  tour  os- 
seous pieces  are  connected  together  by  a  crucial  suture,  and  their 
point  of  junction,  upon  the  median  line,  exists  at  the  union  of  the 
two  anterior  thirds  with  the  posterior  third  of  the  vault.  These 
bones  are  frequently  attacked  with  caries  or  necrosis  in  the  vene- 
rial  disease,  which  frequently  occasions  a  communication  be- 
tween the  nose  and  mouth.  These  accidental  openings  may  be 
made  to  disappear  by  means  of  (obturators)  metallic  plates  suita- 
bly adapted  to  the  deficiency  of  the  parts,  nevertheless,  they  have 
more  or  less  effect  over  the  tone  of  the  voice.  Sometimes  the 
median  suture  of  this  osseous  vault  is  wanting :  then  the  separa- 
tion is  prolonged  backwards,  without  being  carried  forwards  to  the 
lips ;  and  in  this  case  there  is  a  division  of  the  velum  palati.  In 
other  cases  the  separation  is  continued  forwards,  without  being 
extended  backwards  to  the  pharynx,  which  may  be  attended  with 
one  of  two  different  species  of  rnalconformation ;  either  the  me- 
dian fissure  bifurcates,  and  includes  between  the  two  branches 
of  this  bifurcation  the  inter-maxillary  bone,  which  generally  coin- 
cides with  a  double  hare-lip ;  or  there  is  no  bifurcation,  but  the 
fissure  does  not  arrive  at  the  superior  lip  by  following  the  median 
line ;  it  runs  obliquely  forwards  and  outwards  and  corresponds 
with  the  simple  hare-lip.  Finally,  it  is  possible  for  the  palatine 
fissure  to  extend  from  one  extremity  of  the  vault  to  the  other. 

But  an  anomaly  still  more  singular  may  exist.  In  a  male  sub- 
ject, of  about  forty  or  fifty  years,  which  was  brought  into  the  pa- 
villions  of  the  Ecole-pratique,  there  was  neither  horizontal  portion 
of  the  os  palati,  nor  palatine  process  of  the  os  maxillare ;  the 
palatine  membrane  was  twice  its  natural  thickness,  and  as  hard 
as  fibro-cartilage ;  that  of  the  floor  of  the  nostrils  was  in  the  same 
state ;  they  were  separated  from  each  other  by  a  space  of  a  line 
and  a  half,  which  was  filled  with  a  kind  of  mucus,  forming  a 
cavity  intermediate  to  the  palatine  vault  and  the  floor  of  the 
nasal  fossae. 

The  Circumference  of  the  Buccal  Cavity. 

It  presents  for  consideration  only  the  internal  part  of  the  gums, 
in  which  we  find  the  same  elements  as  in  the  vault ;  except  that 
they  are  thicker,  more  vascular,  and  of  a  much  less  compact  tex- 


OF    THE    HEAD.  117 

ture  than  the  palatine  membrane  ;  which  accounts  for  their  being 
more  frequently  subject  to  disease.  In  becoming  continuous 
with  the  mucous  membrane  of  the  superior  paries  of  the  mouth, 
the  gums  block  up,  anteriorly  and  posteriorly,  the  inferior  aper- 
ture of  the  palatine  canals ;  so  that  these  foramina  only  exist, 
properly  speaking,  in  the  skeleton. 

The  internal  surface  of  the  teeth  forms,  anteriorly,  a  groove, 
the  depth  of  which  is  proportionate  to  the  degree  in  which  these 
small  bones  are  inclined  towards  the  lips.  Posteriorly,  between 
the  anterior  pillar  of  the  velum  palati  and  the  last  molares,  there 
is  a  small  space  which  will  admit  the  extremity  of  the  little  finger, 
and  which  generally  corresponds  to  the  internal  surface  of  the 
coronoid  process,  or  rather,  to  its  anterior  margin :  by  means  of 
this  space  the  buccal  cavity  communicates  with  the  large  grooves 
which  separate  the  lips  and  cheeks  from  the  external  surface  of 
the  dental  arches.  When  the  mucous  membrane  of  the  cheeks, 
tongue,  etc.,  is  inflamed  and  swollen,  it  sometimes  insinuates  itself 
into  this  space,  and  is  thereby  painfully  compressed  and  even 
wounded  during  mastication,  in-  consequence  of  advancing  be- 
tween the  teeth.  A  foreign  body,  or  any  instrument  whatsoever, 
might  penetrate  through  this  opening  into  the  cavity  of  the  mouth 
or  pharynx,  notwithstanding  the  jaws  are  firmly  closed,  and  wound 
the  organs  contained  within  them.  In  many  persons,  we  also 
observe  other  small  spaces  between  the  teeth,  which  produce  that 
undulated  appearance  remarked  on  the  borders  of  the  tongue, 
when  it  is  the  seat  of  inflammation. 

We  may  also  remark,  that  the  internal  paries  of  the  alveolae 
becomes  almost  immediately  blended  with  the  palatine  process, 
and  is  shorter  and  stronger  than  the  external.  This  peculiarity 
seems  to  indicate  that  in  applying  the  fulcrum  of  Garengeot's 
key  upon  the  palatine  side  of  the  alveolae,  we  will  be  less  liable 
to  fracture  the  walls  of  these  cavities,  in  extracting  the  teeth, 
than  if  we  should  apply  it  upon  the  outer  side :  the  point  of  sup- 
port, would,  in  fact,  be  more  solid ;  and  as  the  fangs  of  these  teeth 
are  naturally  a  little  curved,  they  would  be  extracted  with  less 
effort. 


118  OF   THE    HEAT). 


The  Inferior  Paries. 

This  paries  is  continuous  with  the  supra-hyoideal  region,  and 
has  no  skeleton.  In  the  middle  of  it  is  the  tongue,  which  fills  the 
mouth  when  it  is  closed.  The  superior  surface  of  the  tongue  is 
free  throughout  its  whole  extent,  and  is  prolonged  by  the  isthmus 
of  the  throat,  to  the  epiglottis.  This  surface  is  convex,  from  be- 
fore backwards,  and  even  transversely ;  however,  it  presents  a 
slight  depression  upon  the  median  line.  Of  its  inferior  surface, 
the  two  posterior  thirds  of  the  distance  from  the  epiglottis  to  the 
tip  is  adherent :  it  is  at  this  part  that  it  receives  the  muscles,  ves- 
sels, nerves,  etc.  Its  anterior  third  is  free,  or  fixed  only  by  a 
membranous  fold  behind  the  symphysis  of  the  chin.  It  is  this 
fold  or  froenum,  which,  when  too  short,  prevents  infants  at  the 
breast  from  protruding  the  tongue  and  performing  suction  prop- 
erly ;  whence  the  indication  of  dividing  it.  When,  on  the  con- 
trary, it  is  too  long,  J.  L.  Petit  and  some  others,  have  supposed 
that  it  would  permit  the  tongue  to  slide  backwards  upon  the  pala- 
tine vault  into  the  pharynx  and  occasion  suffocation.  But  if  these 
apprehensions  are  not  chimerical,  they  are  at  least  exaggerated. 
The  posterior  extremity  of  the  tongue  is  fixed  to  the  os  hyoides 
which  participates  in  most  of  its  movements,  and  which  connects 
the  function  of  speech  with  those  of  deglutition  and  respiration. 

COMPONENT  PARTS  OF  THE  TONGUE. 

I.  Its  Membranous  Envelope. 

Upon  the  dorsal  surface  it  is  very  thick,  and  studded  with  a 
great  number  of  small  eminences  called  papillae.  At  its  posterior 
part,  these  papilla?  are  broad,  flattened,  and  perforated  in  their 
centre :  they  are  perfect  cryptoe,  organs  of  secretion,  and  are 
collected  around  the  excavation  called  "foramen  cacwn"  In  the 
middle,  as  well  as  at  the  tip  and  margins,  where  the  membrane  is 
much  more  delicate,  these  papilla?  become  conical  or  fungiform ; 
they  are  then  small,  erectile,  and  form  the  organs  of  sensation. 
The  examination  of  these  corpuscules  merits  the  greatest  atten- 
tion in  acute  diseases,  and  is  not  without  importance  in  chronic 


OF    THE    HEAD.  119 

affections.  The  shades  of  their  colour  and  their  degree  of  prom- 
inence, afford  innumerable  varieties  in  the  different  derangements 
of  health ;  but,  in  general,  we  may  say  that  if  they  are  pale  and 
but  slightly  developed,  if  the  tongue  is  smooth  and  more  or  less 
loaded,  the  organs  of  digestion,  and  the  stomach  in  particular, 
will  bear  cvacuant  remedies  without  danger,  provided  they  are 
otherwise  indicated ;  whereas,  if  they  are  red,  and  raised  upon 
the  mucous  membrane,  if  they  appear  tender,  we  must  use  them 
with  great  caution.  In  consequence  of  the  compact  texture  of 
this  membrane  upon  the  dorsum  of  the  tongue,  and  its  slight  ex- 
tensibility, chaps  frequently  manifest  themselves  in  it,  and  the 
tumours  which  we  observe  in  it  are  almost  always  hard  and  of 
small  volume.  At  its  most  posterior  part,  it  becomes  attenuated, 
and  forms  three  folds,  two  lateral,  which  envelope  the  glossal  pil- 
lars of  the  velum  palati ;  and  one  central,  which  unites  the  tongue 
to  the  epiglottis.  On  its  inferior  surface  it  is  thin,  supple,  slightly 
adherent,  and  of  a  brownish  colour,  a  tint  which  is  owing  to 
the  transparency  of  the  ranine  veins,  which  it  immediately  covers. 
In  reflecting  itself  upon  the  inferior  paries  of  the  mouth,  the 
mucous  membrane  forms  a  species  of  fringed  crest,  in  which 
there  are  some  adipose  vesicles.  Where  this  crest  unites  with 
that  of  the  opposite  side,  near  the  froenum,  we  find  the  orifice  of 
the  duct  of  Wharton :  the  small  ducts  of  the  sublingual  gland 
open  a  little  farther  back. 

ii.  The  Cellular  Tissue. 

It  is  supple,  very  delicate,  and  sends  off  an  infinite  number  of 
processes  between  the  fleshy  fibres.  It  is  to  the  laxity  of  the 
cellular  element  that  we  must  attribute  the  rapidity  with  which 
the  tongue  sometimes  tumefies,  and  the  enormous  volume  which 
it  may  acquire. 

in.  The  Muscular  or  Proper  Tissue. 

This- tissue  is  composed  of  very  delicate  fibres,  which  intersect 
each  other  in  various  directions,  but  are  principally  directed  from 
before  backwards.  From  the  latter  circumstance  our  incisions 
should  be  longitudinal,  and  when  cancerous  tumours  are  removed 
from  the  end  of  the^  tongue,  they  should  be  included  in  a  trian- 


120 


OF   TlfiJ    HEAD. 


gular  flap,  having  its  base  situated  anteriorly,  in  order  that  we 
may  afterwards  be  able  to  bring  the  two  sides  of  the  division 
parallel  to  the  direction  of  the  muscular  fibres.  These  fibres  are 
derived  from  the  lingualis,  genio-glossus,  hyo-glossus,  stylo-glossus, 
and  several  other  muscles,  with  which  MM.  Bauer,  Blandin,  et 
Gerdy,  have  recently  been  advantageously  occupied. 

iv.  The  Arteries. 

The  tongue  is  very  liberally  supplied  with  arteries  by  the  ex- 
ternal carotid ;  but  there  are  three  only  which  merit  particular 
attention,  viz :  the  dorsalis  linguae,  palatina  inferior,  which  are 
distributed  to  the  neighbourhood  of  the  tonsils  and  the  tissue  of 
these  organs,  and  the  ranina  artery  especially.  This  last  passes 
through  the  inferior  portion  of  this  organ,  and  is  at  first  situated 
deep  between  the  hyo-glossus,  genio-glossus  and  lingualis  mus- 
cles ;  but  as  it  approximates  the  tip  it  becomes  very  superficial, 
being  almost  solely  covered  by  the  mucous  membrane ;  on  this 
account  it  is  very  much  exposed  to  the  action  of  the  instrument 
in  dividing  the  frcenum  Iingua3  in  children.  It  is  for  the  purpose 
of  avoiding  its  division,  in  these  cases,  that  we  should  direct  the 
point  of  the  scissors  downwards  instead  of  upwards.  Further- 
more, this  branch  is  so  large  that  it  will  occasion  a  troublesome 
hoemorrhage,  and  on  account  of  its  tortuous  course,  the  softness 
and  mobility  of  the  tissues  which  envelope  it,  it  will  retract  very 
considerably  when  divided  and  thereby  become  difficult  to  se- 
cure. And  on  the  other  hand,  the  natural  humidity  of  the  parts, 
by  opposing  the  astringent  action  of  the  air  upon  the  divided  tissues 
will  also  render  the  haemorrhage  more  serious.  It  follows,  then, 
from  this  combination  of  circumstances,  that  the  actual  cautery, 
or  compression  with  the  forceps,  un  valet  patina  etc.  are  the  on- 
ly means  which  art  can  employ  when  the  ranine  arteries  are 
wounded. 

v.  T/ie  Veins. 
These  are  more  numerous  and  larger  than  the  arteries,  and 

*A  species  of  forceps  joined  in  the  middle  with  a  screw  (volsella  patini). 
Transl 


OF    THE    HEAD.  \'2l 

communicate  directly  with  those  of  the  amygdalae  and  pharynx ; 
which  explains  the  advantageous  results  which  the  ancients  de- 
rived from  bleeding  from  the  ranine  vein  in  angina  and  other 
diseases  of  the  throat.  They  form  a  net  work,  which  is  princi- 
pally observed  at  the  inferior  surface  of  the  tongue ;  and  it  is  in 
the  free  portion  of  this  surface,  immediately  below  the  mucous 
membrane,  that  these  veins  collecting  form  the  ranine.  This  last 
vein  lies  more  superficially  and  more  externally  than  the  artery, 
and  as  it  is  of  considerable  size,  it  might,  if  opened,  produce  a 
rapid  and  beneficial  degorgement  in  diseases  of  the  mouth  in 
general,  and  of  the  tongue  in  particular ;  but  its  relations  to  the 
artery  must  be  attended  to.  When  we  divide  it,  it  is  better  to  dip 
the  point  of  the  lancet  obliquely  backwards  and  upwards,  and  at 
the  same  time  incline  it  rather  outwards  than  inwards.  This  dis- 
position of  the  venous  system  also  indicates  that  it  is  more  rational, 
in  acute  swellings  and  other  diseases  of  the  tongue  requiring  scari- 
fications, to  make  them  upon  the  sides  of  the  inferior  surface  of 
the  tongue  than  upon  the  dorsal  surface.  It  is  well  to  remark, 
however,  that  the  quantity  of  blood  which  follows  these  incisions 
is  not  always  sufficient  to  account  for  the  sudden  and  sometimes 
surprising  relief  which  they  produce.  In  1818,  there  was  a  pa- 
tient in  the  general  hospital  of  Tours  afflicted  with  an  enormous 
swelling  of  the  spleen  and  daily  vomiting.  About  five  or  six 
o'clock  one  evening  he  felt,  without  any  appreciable  cause,  his 
tongue  begin  to  swell ;  at  eight  o'clock  the  tumefaction  was  con- 
siderable, suffocation  imminent,  and  the  tongue  protruding  from 
the  mouth.  Being  on  the  watch,  we  were  called,  and  made  two 
incisions  with  the  lancet,  and  although  not  more  than  two  table- 
spoonsful  of  blood  were  evacuated,  the  tongue,  on  the  day  follow- 
ing, was  reduced  to  its  natural  size. 

vi.  The  Lymphatics. 
They  pass  to  the  submaxillary  and  cervical  lymphatic  glands. 

vn.  The  Nerves. 

These  are  numerous,  and  are  derived  from  three  branches ; 
the  glosso-pharyngeal  appertains  principally  to  the  base  of  the 

16 


122  OF    THE    HEAD. 

tongue,  and  its  filaments  may  be  traced  even  to  the  lenticular 
papillae ;  the  lingual  branch  of  the  fifth  pair  (?i.  gmtatvrius)  ra- 
mifies freely  in  the  muscular  fibres,  and  terminates  in  the  conical 
and  fungiforme  papillae ;  the  ninth  pair  (hypo-glossal)  is  lost  in 
the  muscles.  It  is  in  consequence  of  these  anatomical  views  that 
the  latter  nerve  has  long  been  considered  as  appertaining  to  mo- 
tion, and  the  two  former  to  the  sense  of  taste  and  the  general 
sensibility.  Some  experiments  had  already  been  tried  in  order 
to  resolve  this  question,  which  only  gave  contradictory  results ; 
but  the  recent  researches  of  M.  Magendie  upon  the  trifacial 
nerve,  have  manifestly  proved  the  above  to  be  the  fact.  From 
this  difference  in  the  action  of  the  nerves  of  the  tongue  we  will 
perceive  the  reason  why  the  taste  sometimes  persists  in  persons 
affected  with  paralysis  of  this  organ,  and  why  the  gustative  func- 
tion is  at  other  times  destroyed  notwithstanding  the  movements 
of  the  tongue  are  free.  We  also  find  several  branches  from  the 
great  sympathetic,  following  the  principal  vessels,  and  distributed 
to  the  base  of  the  tongue  ;  and  it  is  by  means  of  these  filaments 
that  it  participates  with  the  functions  of  the  interior  life. 

VIH.   The  Skeleton. 

In  man  the  tongue  does  not  present  any  skeleton,  but  we  find 
in  its  centre,  upon  the  median  line,  a  fibro-cartilage,  placed  ver- 
tically, (place  de  champ,)*  which  is  prolonged  backwards  towards 
the  epiglottis.  This  plate,  sometimes  indistinct,  gives  attachment 
to  some  fleshy  fibres  which  enter  into  the  composition  of  the 
muscles  of  this  organ,  and  forms  the  only  solid  part  of  it. 

Under  the  mucous  membrane,  between  the  tongue  and  the 
inferior  maxillary  bone,  we  find  the  sublingual  gland  anteriorly, 
and  a  prolongation  of  the  submaxillary  gland  posteriorly.  These 
two  organs  form  in  this  situation  an  elongated  eminence,  which 
is  liable  to  vary  considerably  ;  but  it  should  be  remarked  that  the 
lymphatic  glands  sometimes  become  prominent  here  in  conse- 
quence of  tumefaction,  and  may  be  mistaken  for  a  disease  of  the 
salivary  glands.  If  the  former  should  be  affected  with  cancer 
or  any  other  disease  requiring  extirpation,  we  should  commence 
by  detaching  it  from  the  side  of  the  bone,  at  the  same  time  raising 

*  Blandin,  Archives,  1823. 


OP   THE    HEAD. 

it  with  a  hook ;  it  will  then  be  very  easily  removed  without  in- 
curring any  risk,  provided  the  instrument  does  not  glance  to- 
wards the  ranine  and  sublingual  arteries.  When  the  duct  of  the 
submaxillary  gland  dilates  in  such  a  manner  as  to  form  ranula, 
this  tumour,  being  supported  externally  by  the  jaw,  pushes  the 
tongue  upwards,  and  may  thereby  contract  the  isthmus  of  the 
throat  to  such  a  degree  as  to  endanger  suffocation.  A  remarka- 
ble example  of  this  kind  is  related  by  Burns.  "A  man  called  to 
consult  Mr.  Cline  on  account  of  a  tumour  which  had  existed  for 
a  long  time  under  the  tongue,  and,  while  waiting  in  an  adjoining 
room,  Mr.  C.  heard  the  noise  of  a  fall  and  stifled  groans.  He 
immediately  enters  and  finds  the  man  lying  on  the  floor  and  on 
the  point  of  suffocation.  Suspecting  the  cause  to  be  a  foreign 
body  lodged  in  the  trachea,  he  is  about  to  perform  the  operation 
for  bronchotomy,  when  he  perceives  that  the  tongue  of  the  pa- 
tient is  forced  backward  by  a  large  ranula,  which  is  also  project- 
ing out  of  the  mouth.  He  introduces  the  lancet  and  gives  vent 
to  a  large  quantity  of  pus  and  lymph." 

As  these  tumours,  when  growing,  remove  the  nerves  and  ves- 
sels of  the  tongue  to  a  considerable  distance,  a  very  extensive 
part  of  them  may  be  excised  without  danger. 

According  to  Marochetti,  the  pustules,  which  the  Greek  peas- 
ants and  even  physicians,  among  others  Dr.  Xanthos,  say  are 
developed  under  the  tongue,  from  the  third  to  the  ninth  day  after 
the  bite  of  a  rabid  animal,  would  be  situated  in  the  tubercle 
where  the  excretory  ducts  of  the  sublingual  and  submaxillary 
glands  terminate.  These  pustules,  then,  in  the  opinion  of  this 
surgeon,  must  be  merely  a  dilatation  of  the  extremities  of  these 
canals,  in  consequence  of  an  accumulation  of  the  rabid  virus 
within  them.  If  this  opinion  should  be  confirmed,  and  if  we 
could  be  so  fortunate  as  to  prevent  the  developement  of  hydro- 
phobia by  the  extirpation  of  these  pustules,  the  operation  would 
neither  be  difficult  nor  dangerous ;  for  the  anatomical  relations  of 
the  parts  are  such  that  we  might  penetrate  to  a  sufficient  depth 
in  this  situation,  without  incurring  any  risk  of  wounding  the  arte- 
ries. Nevertheless,  we  think  it  would  be  better  to  seize  the 
vesicle  with  a  hook  or  forceps,  and  remove  it  with  the  curved 
scissors,  than  to  make  use  of  the  scalpel  or  bistoury. 


OF    THE    1IEAI>. 


The  Isthmus  of  the  Throat. 

This  opening  is  formed,  interiorly,  by  the  dorsal  surface  of  the 
tongue ;  superiorly,  by  the  velum  and  velum  pendulum  palati ; 
and  laterally,  by  the  pillars  of  the  velum. 

The  velum  palati  is  a  prolongation  of  all  the  soft  tissues  of 
the  superior  paries  of  the  mouth  and  inferior  of  the  nasal  fossae, 
and  also  includes  a  certain  number  of  muscles  which  determine 
its  movements.  We  consequently  find  in  it,  in  the  first  place,  a 
thick,  slightly  extensible,  and  lacerable  mucous  membrane,  which 
is  generally  of  a  deeper  colour  than  that  of  the  interior  of  the 
nose  and  mouth,  and  lined  by  a  layer  of  filamentous  and  dense 
cellular  tissue,  in  which  there  are  a  great  number  of  very  large 
follicles ;  next,  another  lamellated  membrane,  which  unites  the 
latter  to  the  muscles.  It  is  in  the  first  of  these  tissues  that  puru- 
lent and  cedematous  infiltrations,  etc.,  are  developed,  and  these 
are  the  follicles  which  appear  to  be  the  principal  seat  of  disease 
in  the  various  affections  of  the  velum  palati.  In  these  laminae 
the  principal  nerves  and  vessels  ramify ;  but  they  are  unimpor- 
tant in  a  surgical  point  of  view.  It  is  proper  to  observe,  how- 
ever, that  it  is  very  liberally  supplied  with  venous  capillaries ; 
which  perhaps  will  enable  us  to  explain  the  prompt  and  beneficial 
results  which  some  surgeons  derive  from  touching  the  mucous 
membrane  with  the  nitrate  of  silver  in  certain  inflammations. 

A  man  was  suddenly  attacked  with  a  very  acute  pain  in  the 
upper  part  of  the  mouth,  and,  on  inspection,  we  perceived  a 
reddish  blue  spot,  of  the  size  of  a  two  franc  piece,  upon  the  ante- 
rior surface  of  the  velum  palati,  the  rest  of  the  throat  being  in  its 
natural  state.  We  touched  this  spot  with  the  nitrate  of  silver : 
one  hour  afterwards  the  pain  had  ceased,  and  on  the  day  follow- 
ing the  redness  had  disappeared. 

Next,  the  muscles :  these  are,  the  levatores  palati,  which  draw 
the  velum  towards  the  nasal  fossa? ;  the  tensores  palati,  which 
widen  it  by  drawing  it  horizontally,  in  consequence  of  their  being 
reflected  over  the  hook  of  the  pterygoid  process,  forming  a 
pulley;  the  palato-pharyngseus  and  constrictor  isthmi  faucium. 
which  depress  it  towards  the  base  of  the  tongue ;  lastly,  the 
levator  uvulae,  which  appertains  especially  to  the  uvula.  As  all 


OF    THE    HEAD. 


these  muscles,  with  the  exception  of  the  azygos  uvulae,  lie  upon 
the  sides,  we  may  easily  explain  how  the  separation  which  exists 
between  the  two  halves  of  the  velum  palati,  when  this  organ  is 
divided,  is  produced  ;  but  it  is  not  so  easy  to  account  for  their 
spontaneous  approximation,  in  some  convulsive  actions  of  the 
pharynx,  as  is  frequently  observed,  for  example,  when  the  staphy- 
lorapky  is  performed.  We  had  an  opportunity  of  observing  this 
phenomenon  very  distinctly,  in  a  female  operated  upon  in  June 
by  M.  Roux.  We  in  fact  saw,  and  M.  Roux  directed  our  atten- 
tion to  it  several  times,  the  two  lips  of  the  division  pass  towards 
each  other  and  come  into  contact,  whilst  this  skilful  surgeon  was 
attempting  to  lay  hold  of  them  with  the  forceps  or  tenaculum. 
This  fact  is  not  satisfactorily  explained  to  us  by  the  known 
laws  of  muscular  contraction. 

The  velum,  like  the  vault  of  the  palate,  seems  to  be  formed  by 
the  approximation  of  the  two  lateral  parts.  Now,  if  this  ap- 
proximation is  not  effected,  a  congenital  division  will  be  the  re- 
sult, which  may  exist  alone,  and  thus  form  a  species  of  hare-lip 
in  the  back  part  of  the  mouth  ;  or  it  may  be  accompanied  with  a, 
more  or  less  extensive  separation  of  the  palatine  suture,  which 
being  prolonged  forwards,  may  coincide  with  a  single  or  double 
hare-lip.  It  is  for  the  purpose  of  removing  this  infirmity,  here- 
tofore considered  as  incurable,  that  M.  Roux  invented  the  staphy- 
loraphy.  This  operation,  simple  and  easy  in  itself,  but  delicate 
and  tedious  on  account  of  the  depth  of  the  organs  upon  which  it 
is  necessary  to  act,  has  already  been  performed  by  the  celebrated 
surgeon  of  la  Charite  about  twenty  times  ;  and  if  not  always 
with  complete  success,  at  least  with  a  sensible  amelioration  in 
such  cases  as  would  not  admit  of  a  perfect  reunion.  At  first 
view,  we  might  apprehend  that  the  sutures  would  cut  through 
the  soft  parts  which  they  must  embrace  ;  but  observation  has 
shown  that  this  does  not  happen  ;  and  this  may  be  accounted  for 
by  the  compact  texture  of  the  mucous  membrane,  and  especially 
of  its  cellular  tissue,  which  is  almost  fibrous  ;  by  that  of  the  cir- 
cumflexus  palati,  which  becomes  aponeurotic  in  this  situation; 
and  lastly,  by  that  of  the  azygos  uvula?,  the  entire  body  of  which 
is  comprised  within  the  loop  of  the  ligature.  When  the  attach- 
ment of  the  velum  palati  to  the  posterior  margin  of  the  vault 
participates  in  the  malformation,  it  may  hinder  the  re-union  of 


126  OF   Till:    HEAD, 

the  soft  parts :  in  such  a  case,  M.  Roux  makes  a  transverse  in^ 
cision,  and  separates  this  membrane  on  each  side,  by  carrying  it 
along  the  posterior  border  of  the  floor  of  the  nostrils ;  after  which 
there  is  no  obstacle  to  the  approximation  of  the  scarified  edges 
of  the  wound.  This  operation  is,  without  contradiction,  one  of 
the  most  brilliant  conquests  of  the  surgery  of  the  nineteenth 
century. 

The  free  margin  of  the  velum  palati  is  prolonged  in  its  mid- 
dle by  a  conical  eminence,  the  length  of  which  varies  consider- 
ably.    This  small  body  which  is  indirectly  attached  to  the  pos- 
terior spine  of  the  nasal  fossae,  is  called  uvula,  and  does  not  exist 
in  animals,  unless  it  is  the  ape,  in  which  it  is  very  small.     It  con- 
tains the  same  elements  as  the  velum  palati,  and  its  figure  is 
moulded  upon  the  azygos  uvulae  muscle,  which  retracts  and 
partly  elevates  it.     The  mucous  membrane  forms  the  greater 
portion  of  it ;  indeed,  with  the  follicles,  it  constitutes  the  whole 
of  the  inferior  half  of  its  free  portion.     These  follicles  are  so 
large  and  numerous  that  they  form  a  thick  layer  which  gives  to 
the  uvula  a  very  distinct  glandular  appearance.      M.   Lisfranc 
says  that  there  are  three  in  particular  at  the  extremity  of  this 
organ,  which  are  very  large.     It  is  to  their  swelling,  to  the 
inflammation  of  the  cellular  tissue  which  envelopes  them,  or  to 
serous  effusions  into  the  laminae  of  the  mucous  membrane,  that 
what  is  vulgarly  called  the  falling  down  of  the  palate  is  to  be 
attributed.     Of  whatsoever  nature  this  elongation  may  be,  it 
occasions  much  inconvenience,  and  a  troublesome  cough,  in  con- 
sequence of  the  irritation  which  it  keeps  up  in  the  throat  by  titil- 
lating the  tongue.     In  all  these  cases,  if  it  is  not  indurated,  or  of 
very  long  standing,  cauterizing  it  with  the  nitrate  of  silver  will 
seldom  fail  to  cure.     But  should  this  means  prove  unsuccessful, 
we  must  resort  to  excision  as  the  only  resource  which  holds  out 
a  chance  of  success.     For  this  purpose  the  scissors  invented  by 
Percy,  having  one  of  its  blades  a  little  longer  than  the  other,  and 
bent  towards  the  end  transversely,  so  as  to  prevent  the  organ 
slipping  from  between  the  blades,  are  very  serviceable ;  or  we 
may  seize  the  end  of  the  uvula  with  a  hook  or  forceps,  and  then 
snip  it  off"  with  a  blunt  pair  of  scissors.     When  the  tumefaction 
of  the  uvula  is  very  great,  the  greater  part  of  it  may  be  removed 
without  inconvenience.     Surgeons  have  frequently  supposed  that 


OF   THE    HEAD.  1'27 

they  have  cut  it  off  at  its  root,  when  only  that  portion  of  it  which 
is  below  the  azygos  was  actually  removed,  and  the  congestion  of 
the  tissues  being  relieved  by  the  operation,  they  resume  their 
regular  position;  and  the  uvula  then  appearing  almost  of  its 
natural  length,  some  have  supposed  that  it  was  regenerated. 

Upon  each  side  of  the  uvula,  the  border  of  the  velum  palati 
forms  an  arch  which  bifurcates  in  descending,  in  order  to  form 
the  pillars,  and  thus  constitute  the  lateral  parts  of  the  pharyngeal 
isthmus.  The  anterior  branch  or  pillar  includes  the  glosso-pha- 
ryngoeus  muscle  and  is  lost  upon  the  side  of  the  tongue  ;  the  pos- 
terior descends  into  the  lateral  paries  of  the  pharynx,  and  seems 
to  go  to  attach  itself  to  the  body  of  the  os  hyoides :  this  encloses  the 
palato-pharyngoeus  muscle.  These  two  pillars  consequently  leave 
between  them  a  triangular  space,  the  base  of  which  is  below, 
and  in  which  the  tonsils  are  situated.  These  last  organs  are  com- 
posed of  a  great  number  of  mucous  follicles,  intimately  adherent 
to  the  mucous  membrane,  which  also  sends  numerous  processes 
between  them,  uniting  them  to  each  other.  The  amygdaloe  are 
subject  to  two  species  of  inflammation ;  that  is  to  say,  the  inflam- 
matory state  may  be  developed  in  the  surface  of  the  mucous 
tissue,  which  generally  produces  factitious  membranes  of  differ- 
ent species,  which  may  be  mistaken  for  ulcers  and  even  gan- 
grene ;  or  the  inter-foilicular  and  sub-mucous  cellular  tissue  may 
be  the  principal  seat  of  the  inflammation.  In  the  latter  case,  phleg- 
monous  abscesses  are  disposed  to  form,  and  when  they  frequently 
recur  they  may  occasion  induration.  As  the  use  of  the  knife  is 
frequently  required  in  inflammations  of  the  tonsils  and  their  con- 
quences,  it  is  necessary  to  know  the  exact  relations  of  this  gland, 
especially  its  external  part.  It  is,  in  fact,  in  this  situation  that  it  is 
approximated  to  the  internal  carotid  artery,  from  which  it  is  sep- 
arated, in  the  natural  state,  only  by  the  constrictor  of  the  pha- 
rynx, some  cellular  tissue,  nervous  filaments  and  a  complicated 
venous  plexus.  In  general,  the  artery  is  eight  or  ten  lines  be- 
hind and  external  to  the  gland  ;  so  that  in  plunging  the  bistoury 
between  the  pillars  of  the  velum  palati,  it  would  be  easier  to 
strike  this  vessel  when  the  tonsil  is  in  a  state  of  tumefaction,  as  it 
is  then  carried  near  to  the  artery.  In  order  to  avoid  this  terrible 
accident,  which  must  almost  inevitably  be  mortal,  it  would  be 
better  to  direct  the  point  of  the  instrument  more  towards  the 


OF    T11J3    HEAD. 

pharynx,  than  towards  the  ramus  of  the  jaw.  Notwithstanding 
Burns  relates  one  example,  M.  Portal  a  second,  and  Beclard  a 
third,  this  accident  must  be  very  rare,  and  can  only  happen  to 
those  who,  by  distraction  or  some  other  cause,  have  entirely  for- 
gotten the  anatomy  of  the  posterior  fauces.  In  the  extirpation 
of  this  gland  when  scirrhous,  there  is  still  less  risk,  because  the 
organ  being  drawn  forwards  by  the  forceps,  it  is  scarcely  possible, 
in  cutting  it  out  with  the  scissors  or  bistoury,  to  dip  so  deep  as 
the  artery.  But  it  must  not  be  forgotten  that,  during  this  opera- 
tion, the  velum  palati,  the  pillars  and  tongue  are  alternately  ele- 
vated and  depressed,  so  that  the  gland  appears  prominent  at  one 
moment  and  at  the  next  depressed :  hence  the  advantage  of  using 
the  scissors,  for  although  the  probe-pointed  bistoury  may  be  con- 
ducted by  a  dexterous  hand,  it  will  be  liable  to  wound  other  organs 
unnecessarily.  The  haemorrhage  which  follows  this  operation 
is  sometimes  considerable,  and  proceeds  from  the  very  complex 
net-work  which  is  formed  in  the  tonsil  by  the  superior  and  infe- 
rior palatine  arteries,  and  to  the  tonsillary  circle  which  results 
from  their  anastomoses  being  of  considerable  volume.  But  more 
frequently  the  blood  is  discharged  from  numerous  large  veins, 
which  form  a  species  of  plexus  externally  and  against  the  poste- 
rior wall  of  the  pharynx. 

It  is  in  the  same  depression  in  which  the  tonsils  are  lodged,  and 
upon  the  tonsils  themselves,  that  syphylitic  ulcers  of  the  throat 
are  generally  developed  ;  it  is  also  upon  these  organs  that  croupal 
concretions  begin  to  form  in  the  greater  proportion  of  such  cas- 
es ;  therefore  these  parts  should  be  closely  inspected  when  we 
have  the  least  suspicion  of  these  diseases. 

Sect.  11.  Pharyngeal  Region  or  Cavity. 

Broader  in  the  middle  than  at  its  extremities,  it  seems  formed  of 
two  cones  joined  at  their  base,  the  superior  of  which  is  curved  for- 
wards in  order  to  become  continuous  with  the  nasal  fossae,  whilst 
the  inferior  descends  almost  perpendicularly. 

We  will  consider  the  pharynx  anteriorly,  posteriorly,  laterally, 
superiorly,  and  inferiorly. 


OF   THE   HEAD. 


120 


i.  The  Anterior  Part. 


This  is  the  most  complicated  part,  and  presents,  from 
downwards,  first,  the  posterior  opening  of  the  nostrils,  the  supe- 
rior and  inferior  parietes  of  which  incline  considerably  down- 
wards in  order  to  enter  the  pharynx,  forming  a  curve  and  not  a 
right  angle.  In  consequence  of  this  disposition,  matters  which 
are  rejected  from  the  stomach  easily  enter  the  nose,  when  the 
velum  palati  is  drawn  down,  and,  on  the  other  hand,  sounds  or 
other  foreign  bodies,  readily  descend  into  the  pharynx,  when  they 
have  passed  through  the  nasal  fossae. 

2.  The  posterior  surface  of  the  velum  palati  and  of  the  uvula. 
It  is  important  to  remark  that  this  part  prolongs  the  palatine  vault 
an  inch  and  a  half  backwards  :  whence  it  follows  that  the  secre- 
tions which  come  from  the  nasal  fossae  into  the  posterior  fauces 
fall  behind  the  larynx,  and  are  thereby  removed  from  the  respira- 
tory passages  ;  and  that  it  is  difficult  to  introduce  tubes  into  the 
larynx  through  the  nose  ;  whereas,  by  this  route,  it  is  much  easier 
to  pass  them  into  the  stomach,  than  by  introducing  them  through 
the  mouth. 

3.  The  posterior  buccal  aperture,  which  we  have  examined  in 
the  preceding  region.     This  opening  is  so  disposed  that  it  leads 
very  obliquely  downwards  into  the  pharynx,  or  rather  that  it 
seems  to  continue  the  latter  cavity  upwards  and  forwards  ;  for 
which  reason,  when  the  aliment  is  formed  into  a  ball  upon  the 
base  of  the  tongue,  it  is  carried  by  its  own  weight  into  the  pha- 
rynx, as  soon  as  the  isthmus  faucium  no  longer  opposes  it.     This 
anatomical  disposition  also  explains  why  substances  ejected  from 
the  stomach  have  a  greater  tendency  to  pass  out  by  the  mouth 
than  the  nose,  and  so  much  the  more  so,  as  the  velum  palati  being 
prolonged  into  the  pharynx,  these  substances  as  they  ascend  from 
the  stomach,  strike  against  its  inferior  surface,  and  thus  almost  me- 
chanically apply  it  behind  the  nasal  fossae. 

4.  The  posterior  face  of  the  larynx  and  its  epiglottic  aperture. 
In  the  middle  of  this  portion  we  observe  an  eminence  which  cor- 
responds to  the  cricoid  and  arythenoid  cartilages,  an  eminence 
more  strongly  marked,  but  also  narrower  superiorly  than  inferior- 
ly.      Upon  the  sides  of  this  species  of  crest,  we  distinguish  two 

17 


130  OP   THE    HEAD, 

deep  gutters,  especially  in  repassing  towards  the  mouth,  in  whicl/ 
they  are  gradually  lost  after  having  passed  over  the  sides  of  the 
epiglottis.  Owing  to  these  gutters  and  the  eminence  which  sep- 
arates them,  liquids,  as  they  descend  into  the  oesophagus,  are  na- 
turally divided  into  two  columns ;  which  would  prevent  them 
from  entering  the  larynx,  even  if  the  epiglottis  did  not  exist.* 
They  are  circumscribed  laterally  by  the  internal  surface  of  the 
thyroid  cartilage,  lined  by  its  villous  membrane.  The  laryngeai 
opening  is  a  fissure  about  nine  or  ten  lines  in  length,  and  from  a, 
line  and  a  half  to  three  lines  only  in  breadth ;  broader  towards 
the  arythenoid  cartilages  than  anteriorly,  and  having  its  posterior 
extremity  a  little  more  depressed  than  the  anterior ;  so  that  it 
looks  upwards  and  slightly  backwards.  It  is  surmounted  by  the 
epiglottis,  which  forms  a  species  of  valve  connected  to  the  larynx 
by  a  pedicle  in  the  retiring  angle  of  the  thyroid  cartilage,  and 
upon  the  sides  by  the  arytheno-epiglottic  ligaments.  The  posi- 
tion of  this  cartilaginous  plate  is  such  that  it  does  not  actually 
shut  the  chink  of  the  air-tube  except  during  deglutition,  and  when 
it  is  necessary  to  retain  a  great  quantity  of  air  in  the  lungs,  as,  for 
example,  in  the  act  of  supporting  heavy  burdens,  etc.f :  other- 
'wise  it  is  raised  almost  perpendicularly  ;  so  that  its  anterior  sur- 
face.looks  towards  the  superior  dental  arch,  whilst  its  inferior 
face  regards  the  bottom  of  the  posterior  paries  of  the  pharynx. 
From  this  it  follows  that,  during  expiration,  the  air  is  propelled 
into  the  upper  and  back  part  of  the  latter  cavity,  above  the  velum 
palati,  and  that  its  natural  exit  is  through  the  nostrils.  Hence 
also,  in  order  that  the  epiglottis  should  fall  during  deglutition,  the 
base  of  the  tongue  must  be  elevated.  Consequently,  when  we 
wish  to  introduce  a  tube  into  the  glottis  for  the  purpose  of  estab- 
lishing respiration,  as  in  still  born  children,  or  to  resuscitate  per- 
sons in  the  state  of  asphyxia,  we  must  commence  by  depressing 
the  posterior  extremity  of  the  tongue :  without  this  precaution  the 
instrument  will  generally  penetrate  into  the  pharynx.  For  this 
reason  also  we  are  less  sure  of  introducing  a  canula  into  the  lar- 
ynx when  we  pass  it  along  the  median  line,  than  when  we  slide  it 
upon  the  sides  of  the  base  of  the  tongue.  Furthermore,  it  is  ea- 

*  Magendie. 

f  M.  Isidore  Bourdon,  Recherches  sur  le  raecanisme  de  la  respiration,  etc,,  Paris. 
1820. 


OF   THE    HEAD. 

ster  to  perform  this  operation  by  the  mouth,  because  when  the 
instrument  is  introduced  through  the  nose  it  will  strike  against  the 
posterior  paries  of  the  pharynx,  rendering  it  difficult  to  pass  it 
into  the  larynx  without  hooking  the  extremity  of  the  instrument 
with  the  finger  carried  deep  into  the  throat. 

n.  The  Posterior  Wall 

It  has  no  striking  peculiarities,  excepting  that  its  mucous  mem- 
brane is  very  thick,  especially  superiorly,  and  contains  numerous 
very  large  sebaceous  follicles,  which  very  frequently  become  the 
seat  of  ulceration  and  inflammation.  The  fleshy  layer  of  this 
wall  comprehends  the  three  constrictor  muscles,  and  presents  the^ 
following  relations  :  superiorly  it  is  separated  from  the  atlas  and 
dentatus  and  their  ligaments  by  the  insertions  of  the  rectus  capi- 
tis  anticus  major  and  minor ;  in  descending,  it  is  only  separated 
from  the  forepart  of  the  other  cervical  vertebra?,  upon  the  median 
line,  by  the  ligamentum  commune  anterius,  and  laterally  or  before 
the  transverse  processes,  by  the  rectus  capitis  anticus  major  and  the 
longus  colli.  There  is  not,  therefore,  any  organ  behind  this  wall 
which  it  would  be  dangerous  to  wound ;  and  for  this  reason  cer- 
tain jugglers  introduce  bars  of  iron,  etc.,  of  a  considerable  weight 
into  their  throats  with  impunity ;  the  extremity  of  the  metallic 
rod  which  is  in  the  pharynx,  rests  upon  the  anterior  part  of  the 
vertebrae,  and  the  jaws  maintain  the  equilibrium.  The  posterior 
wall  of  the  pharynx  is  united  to  the  above-mentioned  organs  by 
means  of  a  very  lax  and  very  extensible  lamellated  cellular  tissue, 
in  which  one  of  the  branches  of  the  inferior  pharyngeal  artery 
ramifies  ;  also  veins  of  a  larger  size  and  much  more  numerous, 
which  unite  and  separate  several  times  in  order  to  form  a  plexus, 
their  trunks  finally  terminating  in  the  interal  jugular  vein  ;  lastly, 
some  filaments  of  the  glosso-pharyngeal,  par  vagum  and  great 
sympathetic  nerves. 

in.  The  Lateral  Walls. 

In  their  upper  part  we  meet  with  the  Eustachian  tube,  which 
is  expanded  in  the  form  of  a  funnel,  and  consists  of  a  fibro-carti- 
lage  which  forms  two-thirds  or  three-fourths  of  a  canal  completed 


k  OF    THE 

by  the  mucous  membrane,  which  envelopes  besides  the  whole  oi* 
the  cartilaginous  extremity  in  the  pharyngeal  cavity,  and  also 
lines  its  internal  surface,  extending  to  the  ear.  This  canal  is  situ- 
ated some  lines  behind  the  middle  meatus  of  the  nasal  fossae,  and 
the  notched  portion  of  the  cartilage  looks  forwards  and  upwards. 
Between  the  root  of  the  pterygoid  process  and  the  basilary  apo- 
physis,  there  is  a  cul-de-sac  or  excavation,  into  which  the  ex- 
tremity of  the  probe  might  be  readily  insinuated  in  attempting  to 
introduce  it  into  the  tube  by  the  middle  meatus.  In  fact,  if,  when 
the  end  of  the  instrument  gets  into  the  pharynx,  it  is  raised  in  the 
least  degree  above  what  is  necessary,  and  if  it  does  not  fail  ex- 
actly into  the  guttural  canal  of  the  tympanum,  it  will  almost 
always  enter  this  excavation  :  a  circumstance  which  requires  some 
notice,  because  injections  are  frequently  thrown  into  this  place 
instead  of  the  natural  canal.  In  order  to  avoid  this  mistake,  it  is 
preferable  to  introduce  the  probe  by  the  inferior  meatus,  because 
when  it  has  once  got  behind  the  extremity  of  the  inferior  turbi- 
nated  bone,  it  will  only  be  necessary  to  raise  the  end  of  it  a  little 
outwards  for  it  to  slide  almost  of  its  own  accord  into  the  place 
required ;  and  this  is  occasioned  by  the  levator  palati  muscle, 
which,  as  it  descends  in  the  velum  palati,  represents  a  column 
directed  obliquely  from  above  downwards,  from  behind  for- 
wards and  from  without  inwards.  This  muscle,  the  pterygoid 
process,  and  the  tensor  palati  circumscribe  a  triangle  with  a  supe- 
rior base,  in  which  the  eustachian  tube  is  enclosed  ;  so  that  when 
the  instrument  gets  as  far  as  the  posterior  part  of  the  meatus  or 
of  the  floor  of  the  nasal  fossae,  it  is  precisely  in  the  summit  of  this 
triangle.  Then,  by  tracing  the  gutter  which  it  represents,  to  its 
upper  part,  it  will  enter  directly  into  the  tube ;  we  must  be  care- 
ful, however,  not  to  pass  it  beyond  the  fleshy  pillar,  as  it  would 
then  be  difficult  to  find  the  opening  we  are  in  search  of.  It  is 
also  proper  to  observe  that  the  membranous  duplicature  which 
envelopes  the  inferior  turbinated  bone,  is  generally  lost  in  the  su- 
perior paries  of  the  guttural  duct  of  the  ear ;  which  renders  the 
operation  extremely  easy,  by  attending  to  the  preceding  direc- 
tions. Furthermore,  we  should  bear  in  mind  that  this  duct  is 
directed  outwards,  backwards  and  slightly  upwards,  therefore  we 
should  give  to  the  tubes,  with  which  wre  penetrate  into  it  to  any 


OF    THE    H£AD.  133 

depth,  whether  for  the  purpose  of  breaking  down  obstructions,  or 
conveying  injections,  but  a  very  gentle  curvature. 

The  posterior  pillar  of  the  velum  palati  forms  a  second  column 
which  descends  backwards  and  outwards  into  the  lateral  wall 
of  the  pharynx.  Lower  down,  this  paries  gradually  becomes 
narrower,  and  no  longer  presents  any  thing  of  importance.  The 
characters  of  its  mucous  membrane  are  the  same  as  in  the  prece- 
ding wall  ;  its  follicles  and  villosities  are  abundant,  and  it  is  gen- 
of  a  pretty  deep  colour. 

Its  muscles  are  the  three  constrictors  and  the  stylo-pharyngaeus ; 
the  stylo-hyoidseus,  palato-pharyngseus  and  the  levator  palati  also 
form  a  part  of  it. 

This  wall  corresponds  to  the  parotideal  region,  and  is  conse- 
quently coasted  by  the  primitive  carotid  inferiorly  ;  a  little  higher 
by  the  two  branches  into  which  this  trunk  divides ;  still  higher  by  the 
internal  carotid,  and  throughout  its  whole  extent  by  the  jugular 
vein  which  lies  upon  the  external  surface  of  the  arteries,  and 
which  places  itself  quite  behind,  resting  a  little  on  the  outer  side 
of  the  anterior  cerebral  artery  previous  to  its  entrance  into  the 
foramen  lacerum  posterius ;  by  the  glosso-pharyngeal  nerve 
which  is  partly  lost  in  it ;  by  the  superior  cervical  ganglion,  its  nu- 
merous filaments  and  the  par  vagum  which  are  behind  and 
Between  the  vessels,  as  well  as  by  the  spinal  accessory,  in  the 
superior  part  only ;  finally,  by  the  ninth  pair,  and  more  remotely 
by  the  styloid  process,  the  muscles  which  originate  from  it,  the 
parotid  gland  and  the  external  carotid  artery.  It  is  sufficient  to 
mention  these  relations  in  order  to  show  the  danger  and  severity 
of  wounds  of  this  side  of  the  pharynx,  especially  such  as  are  pro- 
duced by  balls,  and  pointed  or  cutting  instruments  ;  and  they  also 
point  out  the  necessity  of  proceeding  with  the  greatest  circum- 
spection when  performing  operations  in  this  situation. 

iv.  The  Superior  Extremity  or  Vault  of  the  Pharynx. 

This  extremity  is  merely  the  continuation  of  the  posterior  wall 
which  bends  considerably  forwards  in  order  to  become  continu- 
ous with  the  vault  of  the  nostrils.  This  disposition  is  at  least  evi- 
dent with  regard  to  the  mucous  membrane,  which  is  softer, 
thicker  and  redder  in  this  place  than  in  the  rest  of  the  organ.  The 


134 


OI'    THE    HEAD. 


superior  constrictor  muscle  is  attached  very  near  the  sphenoid, 
upon  the  basilary  process,  and  is  separated  more  than  an  inch 
from  the  foramen  magnum  occipitale  by  the  anterior  recti  capitis 
muscles.  In  consequence  of  this  disposition  the  velum  palati, 
when  rising,  soon  comes  in  contact  with  the  vault,  or  superior 
part  of  the  posterior  wall  of  the  pharynx  which  is  inclined  for- 
wards, whereby  it  is  not  necessary  for  this  velum  to  be  applied 
directly  against  the  whole  of  the  pharyngeal  opening  of  the  nasal 
fossae  during  deglutition,  vomiting,  etc.  The  skeleton  which  we 
find  above  the  soft  parts  appertains  to  the  base  of  the  cranium ; 
it  is  composed  of  the  basilary  process  and  of  a  part  of  the  occipito- 
petrous  sutures.  The  principal  bone  being  spongy  and  very 
thick,  the  encephalon  is  found  sufficiently  protected  in  this  situa- 
tion. But  it  is  at  the  posterior  part  of  this  paries,  or,  if  we  prefer 
it,  in  the  commencement  of  the  posterior  wall,  that  we  find  the 
occipito-atloidien  articulation;  and  as  there  is  a  considerable 
space  between  the  os  occipitis  and  anterior  arch  of  the  atlas 
which  is  filled  by  ligaments  only,  a  small  sword,  or  other  instru- 
ment, entering  the  pharynx  and  passing  in  an  oblique  direction 
upwards  and  backwards,  might,  without  great  difficulty,  pene- 
trate the  spinal  canal,  or  cranium,  and  divide  the  medulla  ob- 
longata. 

v.  T/ie  Inferior  Extremity. 

It  becomes  considerably  narrower  and  terminates,  on  a  level 
with  the  cricoid  cartilage,  in  becoming  continuous  with  the  oeso- 
phagus. It  is  on  account  of  the  narrowness  of  this  opening  that 
foreign  bodies,  of  a  certain  magnitude,  are  frequently  stopped  in 
it.  It  should  be  observed  that  the  tissues  composing  the  pharynx 
here  undergo  a  change  of  character :  thus  the  lining  membrane 
which,  in  the  cavity  just  examined,  was  red  and  filled  with  folli- 
cles, has  suddenly  become  pale  and  almost  smooth.  We  might, 
perhaps,  in  this  difference  of  structure,  find  the  reason  why  the 
accidental  membrane,  which  is  formed  in  diphtherite,  or  pellicu- 
lar  inflammation,*  terminates  abruptly  at  the  commencement  of 

*  It  is  thus  that  M.  Bretonneau  designates  certain  affections  hitherto  known  by 
the  name  of  croup,  angina  maligna,  etc.,  and  upon  which  he  is  about  to  give  a  very 
important  work  to  the  public. 


OF    THE    NECK,  135 

Jh.e  oesophagus,  in  most  subjects.  The  muscular  fibres,  which 
were  transverse,  suddenly  take  a  perpendicular  direction,  and 
this  canal  then  separates  entirely  from  the  larynx. 


CHAPTER  II. 

OF  THE  NECK. 

THE  neck  is  that  narrow  part  of  the  body  which  is  situated 
between  the  head  and  thorax,  and  which  varies  in  length  accord- 
ing to  the  degree  of  embonpoint  and  constitution  of  the  individ- 
ual. In  some  it  is  very  short  and  thick,  in  others  the  reverse. 
In  the  first  case,  if  not  owing  entirely  to  embonpoint,  it  generally 
indicates  an  apoplectic  disposition ;  and  a  long  slender  neck  is 
often  observed  in  those  who  are  predisposed  to  phthisis.  We 
divide  it  into  anterior  and  posterior  portions. 

ART.    I.       ANTERIOR   PORTION    OF    THE    NECK. 

This  part  comprehends  all  the  organs  situated  before  the  cer- 
vical vertebrae.  Upon  its  surface  we  observe,  in  the  course  of 
the  median  line  ;  inferiorly,  the  supra-sternal  fossette  ;  and  above 
this  the  laryngeal  eminence ;  more  externally,  another  oblique 
eminence,  which  passes  from  the  sternum  behind  the  ear,  and 
which  is  more  strongly  marked  when  the  head  is  turned  to  one 
side  and  inclined  towards  the  shoulder :  this  is  the  sterno-mastoid 
ridge.  The  supra-sternal  fossette  is  prolonged  between  this  ridge 
and  the  laryngeal  eminence  into  the  parotideal  region,  and  thus 
forms  a  gutter  on  each  side,  which  is  broad  and  pretty  deep  supe- 
riorly, superficial  and  almost  indistinct  in  the  middle,  and  becom- 
ing united  and  blended  with  each  other  in  the  supra-sternal  fos- 
sette. On  the  outer  side  of  the  sterno-mastoid  ridge,  we  see  the 
supra-clavicular  fossa,  bounded  posteriorly  by  the  trapezius. 

This  portion  of  the  neck  is  thus  naturally  divided  into  three 
regions :  first,  a  superior  which  we  call  submaxillary,  supra-hyoi- 
dean  or  sublingual  region ;  secondly,  an  inferior  and  median,  or 
infra-hyoidean  ;  and  lastly,  the  supra-clavicular,  which  is  inferior 
and  lateral. 


136  OF  THE    NECK. 


Sect.  1.  Supra-Hyoidean  Region. 

It  is  bounded ;  superiorly,  by  the  base  of  the  lower  jaw  and 
the  floor  of  the  mouth  ;  a  little  more  posteriorly,  by  the  paroti- 
deal  region  ;  inferiorly,  by  the  os  hyoides  and  its  cornea  arbitra- 
rily prolonged  to  the  sterno-mastoid  muscle ;  laterally,  by  the 
anterior  margin  of  this  muscle.  Broadest  in  the  middle,  it  after- 
wards gradually  becomes  narrower,  in  order  to  terminate  in  a  point 
upon  the  sides.  From  before  backwards  and  from  above  down- 
wards it  forms  an  oblique  plane,  which  rises  or  sinks  in  accordance 
with  the  motions  of  the  tongue  or  larynx.  In  some  individuals  it 
forms  a  very  distinct  semilunar  prominence,  which  is  separated 
from  the  jaw  by  a  groove  of  greater  or  less  depth ;  this  is  called 
the  double  chin.  Posteriorly,  at  its  entrance  into  the  parotideal 
excavation,  it  becomes  more  concave. 

CONSTITUENT    PARTS. 

i.  The  Skin. 

In  women  and  children  this  is  thin,  delicate,  and  very  extensi- 
ble, whilst  in  man  it  is  thicker,  on  account  of  giving  support  to 
the  beard ;  it  often  contains  transverse  wrinkles  which  are  not 
effaced  by  any  position  of  the  head,  and  which  are  produced  by 
the  contractions  of  the  platysma  muscle.  Its  follicles  are  more 
numerous  and  of  larger  size  than  in  the  other  regions  of  the  neck, 
but  less  so  than  in  the  face ;  and  pustular  eruptions,  etc ,  are  of 
more  frequent  occurrence  here  than  in  the  other  regions.  It  is 
very  vascular,  and  is  frequently  the  seat  of  ne/evi  materni,  and 
erectile  tumours. 

n.  The  Subcutaneous  Layer. 

It  is  composed  of  three  laminae : 

The  first  is  formed  by  a  compact  filamentous  cellular  tissue, 
enclosing  adipose  cells,  which  are  usually  very  fine,  but  may  be- 
come quite  large,  in  which  case  they  form  the  submental  promi- 
nence previously  spoken  of.  This  cellular  lamina  unites  the 


OF   THE    NECK.  137 

piatysma  intimately  with  the  skin,  so  that  when  this  muscle  con- 
tracts, it  always  draws  with  it  the  cutaneous  envelope,  and  for  this 
reason  also,  whenever  we  nip  up  a  portion  of  the  latter,  the  sub- 
cutaneous muscle  is  comprised  in  the  gripe.  Finally,  from  this 
arrangement  of  structure,  we  readily  comprehend  why  tumours 
developed  in  this  tissue  are  always  spherical,  prominent,  and 
seldom  acquire  a  large  size  before  they  perforate  the  integu- 
ments. 

The  second  lamina  is  constituted  by  the  piatysma  itself.  Its 
fibres,  sometimes  very  thick,  at  others  scarcely  distinct,  ascend 
obliquely  forwards  and  inwards,  in  order  to  enter  the  regions  of 
the  face,  or  to  attach  themselves  to  the  inferior  border  of  the  jaw;  so 
that  they  leave  between  them,  upon  the  median  line,  a  small 
triangular  space,  the  apex  of  which  is  at  the  chin :  these  are  the 
fibres  which  produce  the  wrinkles  above  mentioned. 

The  third  is  formed  by  a  lamellated  cellular  tissue,  destitute  of 
adipose  cells,  which  unites  the  piatysma  to  the  cervical  aponeu- 
rosis.  This  lamina  is  but  loosely  united  to  the  aponeurosis,  upon 
which  it  slides  with  facility,  but  adheres  more  firmly  to  the  pia- 
tysma and  follows  its  movements.  Beneath  it  the  anterior  jugular 
veins  are  found,  and,  posteriorly,  a  small  portion  of  the  external 
jugular.  In  consequence  of  its  loose  and  lamellated  texture  its 
inflammations  frequently  assume  the  phlegmonous  character,  and 
pus  readily  collects  in  it  in  the  form  of  abcess ;  but  for  the  same 
reason  also,  this  fluid  may  easily  penetrate  downwards,  and  detach 
the  parts  to  a  very  considerable  extent.  Therefore,  these  ab- 
cesses  should  be  opened  as  soon  as  fluctuation  is  evident,  and  in 
dividing  the  piatysma  the  incision  should  pass  parallel  to  its  fibres. 
It  is  well  to  notice  also  that  these  abscesses,  as  well  as  all  other 
tumours  developed  in  this  layer,  may  become  very  large  without 
disorganising  the  skin,  and  yet  retain  considerable  mobility.  This 
peculiarity  may  be  very  useful  in  establishing  the  diagnosis  of 
certain  diseases  of  the  supra-hyoidean  region. 

in.  The  Aponeurosis. 

This  is  a  simple  cellular  layer  in  some  subjects,  but  in  others 
it  is  of  a  very  distinct  fibrous  texture.  This  fascia  originates 
posteriorly,  from  the  parotideal  and  masseteric  aponeurosis ;  an- 

18 


OF    THE    NECK. 

teriorly,  it  is  attached  to  the  base  of  the  lower  jaw  ;  as  it  descend* 
below  the  chin  it  is  thin  at  first,  but  receives  a  very  strong  lamina 
from  the  anterior  belly  of  the  digastricus  before  it  becomes  blended 
with  the  fascia  cervicalis  upon  the  os  hyoides.  Laterally  and 
posteriorly,  it  splits  in  order  to  envelope  the  submaxillary  gland ; 
then  it  is  its  anterior  sheet  only  which  descends  into  the  supra- 
hyoideal  region;  the  posterior  forms  in  the  first  place  a  sheath 
for  the  gland  and  its  duct,  to  the  prolongation  which  it  sends 
between  the  my-lohyoideus  and  hyo-glossus  muscles,  to  the  sub- 
lingual  gland  even,  and  is  finally  lost  in  the  inferior  paries  of  the 
mouth ;  this  sheet  then  gives  off  less  compact  Iamina3  which  are 
insinuated  between  the  muscles  of  the  tongue. 

The  study  of  this  aponeurosis  is  important,  especially  on  ac- 
count of  the  differences  which  it  produces  in  the  developement 
of  diseases  situated  between  its  external  surface  and  the  skin, 
and  those  which  form  behind  or  beneath  it.  For  abscesses,  or 
fluids  collected  in  the  latter  direction,  are  much  disposed  to  take 
their  course  towards  the  mouth  or  pharynx,  on  account  of  the 
resistance  which  they  meet  with  anteriorly,  and  are,  besides? 
with  difficulty  detected  by  the  fluctuation,  which  may  be  obscure 
for  a  long  time,  notwithstanding  the  accumulation  may  be  consider- 
able. The  same  may  be  said  of  other  tumours,  as  they  generally 
acquire  a  great  magnitude  towards  the  deep  seated  parts  before 
they  render  the  surface  prominent.  The  surgeon  should  therefore 
recollect  all  these  particulars,  when  he  wishes  to  open  the  one, 
or  extirpate  the  others.  This  aponeurosis  forms  a  lamellated 
web  in  which  the  direction  of  the  fibres  is  not  very  distinct ;  on 
which  account  it  is  easily  resolved  into  cellular  tissue,  and  is  sub- 
ject to  so  much  variety  in  point  of  thickness. 

iv.  The  Muscles. 

Some  are  appropriated  to  the  movements  of  the  larynx  and 
lower  jaw ;  the  others  appertain  more  exclusively  to  the  tongue. 

The  former  are : — The  anterior  belly  of  the  digastric,  which 
ascends  obliquely  from  the  os  hyoides  to- the  submental  fossettes. 
In  contact  internally  with  its  fellow  of  the  opposite  side,  covered 
anteriorly  by  the  aponeurosis,  and  concealing  behind  it  a  portion  ol 
the  mylo-hyoideus,  this  muscular  bundle  forms  an  inverted  arch 


OF   THE    NECK.  139 

mid  is  found  separated  from  the  os  maxillare  inferius  by  a 
space  which  is  constantly  varying  during  the  elevation  or  de- 
pression of  the  larynx  or  jaw.  This  space  is  always  filled  by  the 
subrnaxillary  gland.  The  posterior  belly  of  the  digastricus,  in 
descending  from  the  parotideal  region,  is  situated  between  the 
facial  artery  which  is  on  its  outer  side,  and  the  ninth  pair  of  nerves, 
the  lingual  artery  and  sometimes  the  facial  vein,  which  are  on  its 
inner  side. 

The  stylo-hyoideus  as  it  approximates  the  great  cornu  of  the 
os  hyoides,  has  the  same  vascular  and  nervous  relations  as  the 
digastricus.  This  small  muscle  presents  nothing  very  remarkable 
in  a  surgical  point  of  view ;  it  bifurcates  in  order  to  give  pas- 
sage to  the  tendon  of  the  preceding,  gives  off  an  expansion  to  the 
cervical  aponeurosis,  and  is  inserted  into  the  bone. 

The  mylo-hyoideus  is  covered  by  the  digastricus,  by  a  portion 
of  the  submaxillary  gland,  by  some  lymphatic  glands,  by  the  sub- 
mental  artery  and  some  cellular  tissue.  Superiorly,  it  is  separated 
from  the  buccal  membrane  by  the  sublingual  gland,  the  mylo- 
hyoidean  nerve,  some  laminated  tissue  and  adipose  vesicles ;  in- 
ternally, it  is  kept  from  being  in  direct  contact  with  the  genio- 
glossus  and  hyo-glossus  by  a  prolongation  of  the  submaxillary 
gland,  its  duct,  the  ninth  pair  of  nerves,  the  gustatory,  and  the  lin- 
gual artery ;  but  at  its  most  anterior  part  it  touches  the  genio- 
hyoideus,  a  thin  layer  of  lamellated  cellular  tissue  only  intervening. 

The  genio-hyoideus  forms  a  small  column  which  descends  from 
a  rough  protuberance  within  the  arch  of  the  jaw  upon  the  body 
of  the  os  hyoides,  and  seems  to  be  merely  the  most  inferior  bundle 
of  the  genio-glossus. 

The  latter  are : — The  hyo-glossus,  which  is  perforated  by  the 
lingual  artery  obliquely  from  without  inwards,  from  below-up- 
wards,  and  from  behind  forwards,  some  lines  above  its  attachment 
to  the  os  hyoides ;  so  that  the  vessel  covers  a  small  portion  of  the 
external  surface  of  the  muscle  posteriorly,  whilst  it  is  afterwards 
covered  by  the  internal  surface  of  the  latter.  This  muscle  is 
separated  from  the  aponeurosis  and  jaw  by  the  termination  of  the 
stylo-hyoideus  muscle,  the  tendon  of  the  digastricus,  the  ninth 
pair  of  nerves,  a  great  part  of  the  submaxillary  gland,  the  facial 
artery  and  veins,  some  lymphatic  glands  and  the  gustatory  nerve ; 
anteriorly  and  superiorly,  by  a  small  portion  of  the  sublingual  gland 


140  OF   TJ1E    AECK. 

and  of  the  mylo-hyoideus.  All  these  parts  are  lodged  in  a  trian- 
gular space,  the  internal  side  of  which  is  formed  by  the  muscle,  the 
superior  by  the  jaw,  and  the  inferior  by  the  aponeurosis.  This 
space  is  lost  posteriorly  in  the  parotideal  region ;  anteriorly,  it  is 
prolonged  towards  the  tongue  between  the  mylo-hyoideus  and 
genio-glossus.  Its  internal  surface  is  separated  from  the  genio- 
glossus  only  by  the  lingual  and  sublingual  arteries  inferiorly  and 
anteriorly,  and  by  the  lingualis  muscle  superiorly.  As  the  hyo- 
glossus  muscle  is  not  attached  to  the  maxillary  bone,  its  relations 
are  not  altered  by  the  amputation  of  the  jaw. 

The  stylo -glossus  is  a  small  bundle  which  is  expanded  behind 
the  preceding,  and  is  interposed  between  the  internal  jugular  vein 
and  internal  carotid  artery,  and  the  nerves  which  come  out  at  the 
foramen  lacerurn  posterius,  situated  internally ;  the  external  ca- 
rotid, the  facial  and  lingual  arteries  and  veins,  the  ninth  pair  of 
nerves  and  the  gustatory,  externally.  In  the  latter  direction  it 
is  also  covered  by  the  submaxillary  gland  or  a  prolongation  of 
the  parotid. 

The  genio-glossus,  which  is  the  largest  and  most  important 
muscle,  is  attached  by  its  extremity  to  the  rough  protuberance 
within  the  arch  of  the  lower  jaw.  Its  fibres  diverge  in  the  form 
of  a  fan,  and  terminate  throughout  the  whole  extent  of  the  infe- 
rior surface  of  the  tongue.  It  is  separated  from  its  fellow  by  a 
thin  cellular  layer  only;  anteriorly,  it  rests  upon  the  genio-hyoi- 
deus,  and  is  covered  externally  by  the  sublingual  gland,  which 
separates  it  from  the  mylo-hyoideus,  by  the  lingual  artery,  the 
ninth  pair  and  gustatory  nerves,  and  the  hyo-glossus  muscle ;  be- 
sides, quite  superiorly,  by  the  lingualis  muscle  which  separates 
it  posteriorly  from  the  preceding.  As  the  principal  action  of  the 
genio-glossus  is  to  bring  the  base  of  the  tongue  forwards  during 
deglutition,  whilst  at  the  same  time  it  raises  the  larynx  by  drawing 
it  in  the  same  direction,  it  follows  that  these  movements,  after 
the  amputation  of  the  jaw,  may  be  interrupted  ;  a  circumstance 
which  constitutes  the  chief  obstacle  to  the  complete  success  of 
this  operation.  In  fact,  after  the  removal  of  the  chin,  this  muscle 
has  no  longer  any  fixed  point ;  consequently  the  pharynx  can  no 
longer  be  distended  in  its  antero-posterior  direction,  because  the 
tongue  and  larynx  arc  then  merely  elevated  and  depressed  without 
being  carried  forwards.  Deglutition  is  thereby  rendered  very 


OP  THE   NECK.  141 

difficult,  if  not  impossible,  unless  assisted  by  artificial  means ;  and 
notwithstanding  the  jaw  may  have  been  removed  with  all  neces- 
sary dexterity,  and  the  operation,  as  such,  has  perfectly  succeeded, 
the  patient  has  only  exchanged  a  dangerous,  perhaps  mortal  dis- 
ease, for  an  infirmity  which  is  also  capable  of  conducting  him  to 
the  tomb.  These  remarks,  which  have  also  been  made  by  Pro- 
fessor Richerand,  are  unfortunately  too  true,  for  we  have  seen 
several  individuals  perish  from  this  cause.  One  of  these  wras  a 
man  fifty  years  of  age,  who  was  admitted  into  the  hospital  of  St. 
Louis  with  an  enormous  cancer  of  the  jaw.  It  was  amputated 
by  M.  Richerand  just  posterior  to  the  mental  foramina ;  the  two 
ends  were  slightly  approximated,  and  cellular  granulations  filled 
up  their  interval  which  were  soon  converted  into  a  fibrous  sub- 
stance ;  at  the  end  of  three  weeks  every  thing  appeared  as  fa- 
vourable as  possible,  and  the  cicatrix  seemed  solid  ;  soups  were 
given  to  the  patient,  but  he  could  not  make  them  pass  towards 
the  pharynx,  so  that  it  became  necessary  to  inject  them  into  this 
cavity.  He  became  gradually  exhausted,  and  at  length  died  six 
weeks  after  the  operation,  as  much  from  inanition  as  from  the 
suffocation  produced  by  the  thick  saliva  and  mucus  which  ac- 
cumulated in  the  posterior  fauces  in  consequence  of  the  immo- 
bility of  the  tongue.  From  this  fact  we  may  conclude  that  the 
amputation  of  the  anterior  part  of  the  inferior  maxillary  bone  is 
a  very  serious  operation,  and  that  it  should  never  be  performed 
unless  its  necessity  is  positive,  and  even  then  it  should  be  avoided 
if  the  disease  extends  beyond  the  depressor  anguli  oris.  Never- 
theless, M.  Dupuytren  appears  to  have  obtained  complete  suc- 
cess in  a  considerable  number  of  cases ;  which  ought  to  encour- 
age surgeons.  This,  however,  can  only  be  explained  by  admitting 
that  the  portion  of  bone  removed  was  but  small,  and  that  during 
cicatrization  the  divided  extremities  of  the  genio-glossi  and  genio- 
hyoidei  muscles  became  agglutinated  to  the  posterior  surface  of 
the  new  chin.* 

The  lingualis  muscle  was  noticed  when  treating  of  the  tongue. 

*  Since  this  article  was  written  we  have  seen  M.  Dupuytren  perform  this  section 
of  the  jaw  in  a  very  remarkable  case*  The  disease  obliged  this  surgeon  to  saw  oft 
the  bone  as  far  back  as  its  ascending  branches.  A  month  has  elapsed  since  this 
operation  and  the  patient  is  almost  cured.  In  consequence  of  this  fact  we  must 
modify  the  opinion  which  we  have  just  expressed  in  relation  to  this  operation  ;  but 


142  OF    THE    KEOK* 


v.  The  Arteries. 

Posteriorly,  we  find  a  small  portion  of  the  two  carotids.  The 
external  is  the  outer  side  of  the  internal,  and  is  crossed  on  this 
side  by  the  digastric  and  stylo-hyoideus  muscles,  the  ninth  pair 
of  nerves,  and  covered  by  the  parotid  gland  and  aponeurosis ;  be- 
hind this  artery  we  see  the  internal  jugular  vein,  the  anastomotic 
branches  of  the  great  symphathetic  nerve  and  of  the  first  cervical 
pair ;  internally,  it  is  separated  from  the  internal  carotid  by  the 
inferior  pharyngeal  artery,  the  stylo-glossus  and  stylo-pharyngaeus 
muscles. 

The  relations  of  the  internal  carotid  artery  are  the  same  here 
as  were  pointed  out  in  the  pharyngeal  and  parotideal  regions. 

The  facial  or  external  maxillary  traverses  this  region  in  the 
direction  of  a  line  drawn  from  the  posterior  extremity  of  the 
great  cornu  of  the  os  hyoides  to  the  anterior  part  of  the  masseter. 
In  this  track  it  is  tortuous  and  is  covered  by  the  digastricus  and 
stylo-hyoideus  muscles,  the  facial  vein  and  especially  the  sub-max- 
illary gland,  in  the  posterior  and  internal  part  of  which  it  is  some- 
times imbedded  ;  more  externally,  by  the  aponeurosis,  platysma 
and  skin ;  also  by  several  lymphatic  glands ;  internally,  it  rests 
upon  the  stylo-pharyngseus,  constrictor  medius  and  hyorglossus 
muscles,  previous  to  its  curving  over  the  border  of  the  jaw.  Be- 
neath this  bone  it  gives  off  the  sub-mental,  which  runs  along  the 
attachment  of  the  mylo-hyoideus,  and  passes  between  this  mus- 
cle and  the  anterior  belly  of  the  digastric,  in  order  to  anastomose 
with  its  fellow  of  the  opposite  side.  This  is  the  only  branch 
which  must  necessarily  be  divided  in  the  amputation  of  the  an- 
terior portion  of  the  lower  jaw,  and  it  seldom  occasions  a  trou- 
blesome haemorrhage;  should  it,  it  may  be  readily  tied.  Pre- 
vious to  giving  off  the  submental,  the  facial  artery  distributes 
several  very  large  branches  to  the  substance  of  the  submaxillary 
gland,  which  render  the  extirpation  of  this  organ  difficult.  Final- 
ly, still  nearer  its  origin,  this  trunk  sends  some  dorsal  branches  to 

it  requires  all  the  skill  and  dexterity  of  M.  Dupuytren  in  order  to  succeed  in  similar 
cases.  We  must  remark,  however,  that  M.  Graefe  of  Berlin,  one  of  the  most  cele- 
brated surgeons  in  Germany,  has  gone  still  farther,  and  has  dared  to  disarticulate 
the  lower  jaw,  removing  it  in  toto. 


OF   THE    NECK.  143 

the  tongue,  others  to  the  surrounding  parts ;  but  the  latter  do  not 
deserve  particular  attention. 

From  this  somewhat  superficial  disposition  of  the  facial  artery, 
we  see  that  it  may  be  wounded  either  accidentally  or  during 
operations,  and  especially  if  we  attempted  to  remove  the  sub- 
maxillary  gland.  Consequently,  it  is  proper  to  remark  that  it  is 
not  difficult  to  place  a  ligature  around  it,  and  we  think  that  this 
should  be  done  previous  to  attempting  to  remove  tumours  situat- 
ed deep  under  the  jaw,  in  the  direction  of  this  artery,  even  if  they 
are  not  of  large  size.  It  may  be  easily  discovered  between  the 
cornu  of  the  os  hyoides  and  the  submaxillary  gland,  by  making 
an  incision  from  the  latter  organ  to  the  anterior  edge  of  the  ster- 
no-mastoid  muscle,  in  the  direction  of  the  line  indicated  above. 
We  will  have  to  divide  the  skin,  the  platysma  enveloped  between 
its  two  cellular  laminae ;  the  aponeurosis,  from  which  the  artery 
is  separated  only  by  some  cellular  tissue,  and  sometimes  the  fa- 
cial vein,  between  the  submaxillary  gland  and  the  digastric 
muscle. 

The  lingual  artery  is  situated  a  little  lower  than  the  preceding, 
and  on  its  inner  side  ;  before  it  passes  into  the  hyo-glossus  mus- 
cle, it  is  crossed  by  the  nerve  of  the  ninth  pair.  Thus  far  its 
relations  with  the  muscles  are  the  same  as  those  of  the  facial ; 
afterwards,  as  it  passes  between  the  hyo-glossus  and  genio- 
glossus  muscles,  it  is  accompanied  by  the  ninth  pair  of  nerves, 
which  runs  along  its  inferior  and  outer  side.  After  having  given 
off  the  sublingual,  it  takes  the  name  of  ranine  artery.  In  its 
course  from  the  os  hyoides  to  the  superior  part  of  the  hyo-glossus 
muscle,  it  sends  off  some  small  branches,  among  which  we  dis- 
tinguish the  inferior  palatine  artery,  which  is  distributed  to  the 
tonsil,  etc.,  and  sometimes  the  submental,  when  it  does  not  ori- 
ginate from  the  facial. 

It  follows  from  these  relations,  that,  in  order  to  apply  a  ligature 
upon  the  lingual  artery,  as  Beclard  has  advised  in  different  dis- 
eases of  the  tongue,  and  fungus  hcematodes  especially,  the  incis- 
ion should  approximate  a  little  nearer  the  horizontal  line  than  the 
anterior  margin  of  the  masseter,  so  that  if  its  anterior  extremity 
was  prolonged  it  would  come  out  at  the  chin.  The  ligature 
must  also  be  placed  some  lines  below  the  submaxillary  gland : 
then  we  may  seize  the  artery,  separating  the  nerve  which  crosses 


144  OF   THE    NECK. 

it,  behind  the  hyo-glossus ;  or  even  under  this  muscle,  by  dividing 
the  fibres  which  form  a  very  thin  layer  over  the  vessel.  Finally, 
in  order  to  avoid  confounding  this  trunk  with  that  of  the  facial 
artery,  we  must  recollect  that  the  latter  passes  above  and  within 
the  submaxillary,  whilst  the  lingual  is  situated  lower  down. 

vi.  The  Veins. 

These  are  larger,  more  numerous,  and  generally  less  tortuous 
than  the  arteries,  the  direction  of  which  they  do  not  exactly  fol- 
low ;  the  facial  vein,  especially,  should  be  examined  under  these 
different  relations.  At  first  it  is  external  to,  then  behind  the 
artery  of  the  same  name,  and  afterwards  separates  from  it  as  it 
descends,  passing  over  the  external  surface  of  the  digastric  and 
stylo-hyoid  muscles,  in  order  to  terminate  in  the  internal  jugular 
vein.  In  its  course  from  the  genial  to  the  submaxillary  region, 
the  facial  vein  usually  plunges  under  the  aponeurosis ;  but,  some- 
times, on  the  contrary,  it  runs  between  the  facia  of  the  neck  and 
the  platysma ;  in  which  case  it  forms  what  is  called  the  anterior 
jugular,  and  then  terminates  somewhat  lower  down  in  the  exter- 
nal jugular.  Nevertheless,  the  anterior  jugular  may  exist  at  the 
same  time  that  the  facial  follows  its  habitual  track. 

The  other  veins  of  the  region  generally  surround  the  arteries, 
and  empty  their  blood  into  the  internal  jugular. 

vii.  The  Lymphatic  Glands. 

They  are  very  numerous  :  several  of  them  are  situated  behind, 
external  to,  and  before  the  carotids ;  others  surround  the  sub- 
maxillary gland ;  there  are  two  or  three  above  this  gland,  lying 
upon  the  facial  vessels ;  and  lastly,  we  find  some  between  the 
mylo-hyoideus  muscle,  the  jaw,  the  digastricus,  and  the  aponeu- 
rosis. As  these  different  glands  receive  the  lymphatics  of  the 
pharynx,  of  the  interior  of  the  mouth  and  of  the  face,  it  follows 
that  they  soon  become  enlarged  in  consequence  of  inflammatory 
affections  of  the  gums,  cheeks,  tonsils,  &c.;  especially  from  such 
as  produce  morbid  secretions.  The  examination  of  these  organs 
therefore  is  of  great  importance,  as  it  may  lead  us  to  detect  dis- 
eases in  the  organs  from  which  their  lymphatics  originate,  the 


OF    THE    NECK.  145 

existence  of  which  we  might  not  otherwise  suspect,  and  may 
prevent  us  from  mistaking  them  for  other  diseases  which  occa- 
sionally occur  in  their  vicinity.  Thus  the  tumefaction  of  those 
in  the  neighborhood  of  the  carotids  might  be  mistaken  for  aneu- 
rism ;  of  those  which  surround  the  submaxillary  gland,  for  an 
enlargement  of  this  gland  itself;  and  of  those  above  it,  which 
are  bound  down  to  the  jaw  by  the  aponeurosis,  for  adherent  can- 
cers, which  it  would  be  imprudent  to  meddle  with.  On  this 
occasion,  we  will  say,  with  Colles,  Burns,  etc.  that  the  most  part 
of  what  have  been  considered  as  extirpations  of  the  submaxillary 
gland,  may  be  set  down  as  removals  of  enlarged  lymphatic 
glands. 

In  October  1823,  a  young  person,  aged  20  years,  was  admit- 
ted into  the  hospital  of  the  School  of  Medicine,  with  a  very  hard 
tumour  of  the  size  of  a  hen's  egg  under  the  jaw,  in  the  situation 
of  the  submaxillary  gland.  The  opinions  respecting  the  seat  of 
this  tumour  differed.  Some  thought  that  it  was  a  tumefaction  of 
one  or  more  lymphatic  glands ;  others,  an  enlargement  of  the 
submaxillary  gland  itself.  Nevertheless,  it  was  recommended  to 
remove  it,  and  Prof.  Bougon  performed  the  operation.  When 
the  disease  was  extirpated,  a  deep  cavity  was  seen  between  the 
os  maxillare  and  the  hyo-glossus  muscle,  and  at  that  moment  it 
was  believed  that  the  salivary  gland  had  been  removed ;  but  on 
further  examination,  it  was  found  to  be  merely  pushed  inwards, 
and  that  the  extirpated  tumour  consisted  solely  of  several  disor- 
ganised lymphatic  glands. 

vin.  The  Sub-maxillary  Gland. 

This  gland  is  enclosed  in  a  fibrous  sac,  which  is  formed  by  a 
process  of  the  parotideal  sheath  and  of  the  posterior  sheet  of  the 
aponeurosis,  as  heretofore  described.  Posteriorly,  it  is  fre- 
quently continuous  with  the  parotid  gland :  anteriorly,  it  bifur- 
cates in  order  to  embrace  the  posterior  margin  of  the  mylo-hyoi- 
deus  muscle,  and  its  fibrous  envelope  sends  off  a  process  to  the 
glandular  portion  within  this  muscle,  which  forms  a  sheath  for  it 
and  its  duct,  and  is  afterwards  expanded  over  the  sub-lingual 
gland.  The  sub-maxillary  gland  fills  almost  the  whole  of  that 
prismoidal  space  which  was  pointed  out  when  speaking  of  the 

19 


146 


Ol-    THE    ISiECK, 


hyo-glossus  muscle ;  in  fact,  externally  and  infenorly,  it  touches 
the  aponeurosis  and  may  be  felt  under  the  skin ;  the  facial  vein 
also  sometimes  rests  upon  it  in  this  direction.  Externally  and 
superiorly,  it  rests  against  the  inner  surface  of  the  lower  jaw ; 
and  it  is  by  this  side  that  it  receives  the  expansion  of  the  mylo- 
hyoid  nerve :  internally,  it  is  separated  from  the  mylo-hyoideus 
muscle  by  a  cellular  lamina,  the  gustatory  and  lingualis  nerve  ; 
and  lastly,  at  its  posterior,  internal,  and  superior  part,  we  find  the 
facial  artery,  which  lies  so  close  to  it  in  some  subjects,  that  it  is, 
as  it  were,  imbedded  in  its  granulations.  The  lingual  artery  is 
never  adherent  to  it,  but  is  always  found  opposite  to  the  inner 
surface  of  its  inferior  border,  from  which  it  is  soon  separated  by 
the  thickness  of  the  hyo-glossus  muscle.  ,  Limited  inferiorly  by 
the  arch  of  the  digastricus,  the  gland  follows  all  the  movements 
which  this  muscle  communicates  to  the  larynx  ;  therefore,  when 
we  wish  to  render  it  as  prominent  as  possible,  the  head  should  be 
thrown  backwards ;  and  this  is  the  best  position  in  which  to  place 
the  patient  when  we  wish  to  extirpate  this  organ.  From  what 
has  been  said  when  on  the  lymphatics,  it  may  be  inferred  that 
we  are  doubtful  whether  this  operation  has  ever  been  performed  ; 
besides,  the  anatomical  relations  of  the  parts,  as  has  been  de- 
scribed, must  render  it  difficult  and  very  dangerous,  unless  the 
facial  artery  is  previously  secured ;  and  even  then,  the  gustatory 
and  lingualis  nerves  are  very  liable  to  be  wounded.  If,  however, 
the  gland  alone  was  diseased,  being  as  it  were  encysted,  we  think 
that,  having  tied  the  artery,  it  would  be  possible  to  extirpate  it 
without  wounding  those  organs  which  it  is  important  should  be 
avoided. 

The  Canal  of  Wharton  (Submaxillary  duct)  is  always  found  in 
that  process  which  insinuates  itself  between  the  mylo-hyoideus 
and  genio-glossus  muscles,  in  order  to  reach  the  sublingual  gland 
and  the  sides  of  the  froenum.  The  two  principal  nerves  of  the 
tongue  run  above  and  below  it  to  a  certain  distance.  It  consists 
of  three  tunics,  the  firmest  of  which  is  the  sheath  it  derives  from 
the  aponeurosis.  It  is  its  dilation  that  constitutes  ranula,  and  its 
relations  show  that,  if  it  is  true  that  we  can  remove  a  large  por- 
tion of  this  tumour  by  the  mouth  without  danger,  it  would  not  bo 
the  same  by  the  submaxillary  region. 


OF   THE   NECK.  14? 


ix.  The  Nerves. 

They  are  deep-seated  and  superficial. 

Among  the  former  we  find  the  Hypoglossal  (Motor  Linguae. 
S.  Lingualis,  S.  Ninth  pair)  which  is  at  first  situated  on  the  outer 
side  of  the  external  carotid  artery,  within  and  above  the  stylo- 
hyoid  and  digastric  muscles,  then  passes  below  the  submaxillary 
gland,  crosses  the  lingual  artery,  and  ascends  upon  the  external 
surface  of  the  hyo-glossus,  to  the  anterior  part  of  which  it  dis- 
tributes numerous  filaments,  in  order  to  terminate  in  the  tongue. 
This  trunk,  which  establishes  a  communication  between  the  fifth 
and  eighth  pairs  by  means  of  its  supra-hyoideal  and  glossal  fila- 
ments ;  which  in  the  second  place  forms  a  communication  be- 
tween its  branches  and  the  cervical  plexus  by  means  of  the  ramus 
descendens  n&ni,  might  be  easily  exposed  almost  throughout  its 
whole  extent,  and  especially  in  the  direction  of  a  semi-circular 
line  commencing  at  the  anterior  margin  of  the  sterno-mastoid 
muscle,  on  a  level  with  the  angle  of  the  jaw,  and  terminating  upon 
the  body  of  the  os  hyoides :  the  incision  should  then  follow  the 
curve  which  separates  the  inferior  semi-circumference  of  the 
submaxillary  gland  from  the  digastric  muscle.  2d,  The  Lingual 
branch  of  the  trifacial  (Gustatory),  which  descends  below  the 
mucous  membrane  of  the  mouth,  above  the  submaxillary  gland, 
between  the  superior  part  of  the  hyo-glossus  muscle,  to  which  it 
is  very  closely  approximated,  and  the  internal  surface  of  the  os 
maxillare,  from  which  it  is  separated  by  the  gland.  Having 
reached  the  anterior  portion  of  the  hyo-glossus  muscle,  this  nerve 
then  perforates  the  genio-glossus,  in  order  to  be  distributed  to  the 
papillae.  Previous  to  this,  however,  it  anastamoses,  on  the  one 
hand,  above  the  secretory  organ,  with  the  mylo-hyoidean  fila- 
ments of  the  inferior  dental  nerve ;  on  the  other,  with  the  hypo- 
glossal,  and  then  dips  into  the  muscular  fibres,  on  the  inner  side 
of  the  salivary  duct  of  Wharton.  If  it  should  be  required  to 
divide  this  nerve,  we  would  be  obliged  to  seek  for  it  behind  the 
branch  of  the  jaw,  because  it  would  be  almost  impossible  to  ex- 
pose it  in  the  region  under  consideration. 

At  the  posterior  part  we  also  find  some  filaments  of  the  glosso- 
pharyngeal,  and  especially  the  par  vagum  and  great  sympathetic 


IIS  OF    THE    JNECK. 

(ganglionnaire)  which  descend  behind  the  carotids  and  interna* 
jugular. 

The  superficial  nerves  are  derived  from  the  cervical  plexus  and 
the  inferior  branch  of  the  facial  (portio  dura).  The  former  run 
upon  the  external  surface  of  the  aponeurosis ;  the  latter  are  prin- 
cipally distributed  through  the  cellular  tissue  which  lines  the  pla- 
tysma.  These  different  filaments  interosculate  freely  with  each 
other,  and  as  they  are  numerous  and  enclosed  in  a  dense  tissue, 
they  account  for  the  acute  sensibility  of  the  skin  in  this  region, 
and  for  the  violent  pains  and  nervous  disorders  which  sometimes 
accompany  its  inflammations. 

x.  The  Cellular  Tissue. 

Between  the  muscles  it  is  very  delicate  ;  under  the  aponeuro- 
sis, it  is  lamellated,  and  encloses  adipose  vesicles.  The  submax- 
illary  gland  also  contains  a  considerable  quantity  of  it,  which 
envelopes  each  of  its  granulations  between  which  we  observe 
filamentous  processes  from  its  aponeurosis. 

It  is  from  this  cellular  tissue  that  the  pus  is  secreted  when  in- 
flammation is  developed  in  this  salivary  organ.  And  the  same 
may  be  observed  with  respect  to  the  parotid  and  all  glands  of  the 
same  species ;  which  is  owing  to  the  glandular  tissue  being  ap- 
parently insusceptible  of  inflammation  or  at  least  of  suppuration.* 
But  this  suppuration  may  be  consecutive  to  swellings  occurring  in 
the  submaxillary  gland,  in  consequence  of  inflammation  of  the 
mucous  membrane  extending  into  the  roots  of  its  canal,  a  circum- 
stance which  frequently  happens. 

xi.  The  Skeleton. 

Properly  speaking  there  is  no  skeleton  in  the  supra-hyoideal 
region ;  the  only  solid  parts  which  can  be  made  to  enter  into  its 
composition  are  the  os  hyoides  and  the  inferior  half  of  the  internal 
surface  of  the  os  maxillare  inferius.  The  former,  almost  rudi- 
mental  in  man,  whilst  in  other  vertebres  it  forms  a  very  compli- 
cated bone,f  is  sometimes  prolonged  to  the  styloid  process  by 

*  Gariot,  maladies  de  la  bouche,  etc. 

t  M.  Geoffrey  Saint  Hilaire,  by  joining  to  it  the  styloid  processes,  divides  this 


OF    THE    NECK.  i4(J 

means  of  the  stylo-hyoid  ligament,  which  is  then  ossified.  It  is 
on  this  account  that  the  small  cornu,  which  gives  origin  to  this 
prolongation,  usually  contains  several  osseous  granules.  Such  a 
disposition,  if  it  was  recognised,  might  be  a  good  guide  to  the  dis- 
covery of  the  facial  and  lingual  arteries,  etc. 

Be  this  as  it  may,  the  os  hyoides  give  attachment  to  almost  all 
the  depressors  of  the  tongue  and  jaw,  and  levators  of  the  larynx. 
Hence  it  follows  that  a  wound  which  would  divide  transversely 
the  parts  above  this  bone,  would  be  extremely  dangerous,  inde- 
pendent of  haemorrhage,  by  paralysing  all  the  movements  con- 
fided to  these  muscles.  It  is  proper  to  observe  that  a  wound  of 
this  nature  would  pass  above  the  epiglottis,  and  consequently 
would  not  interfere  much  with  respiration. 

The  second  portion  of  the  skeleton  of  this  region  presents  the 
genian  process  (the  rough  protuberance  within  the  mental  arch), 
into  which  the  genio-glossus  and  genio-hyoideus  muscles  are  in- 
serted ;  the  sub-genian  fossette,  for  the  insertion  of  the  digastric- 
us ;  the  sublingual  excavation,  for  the  gland  of  this  name ;  the 
submaxillary  fossa,  which  is  prolonged  to  the  angle ;  and  more 
superiorly,  the  mylo-hyoid  crest.  It  thus  forms  a  solid  paries, 
and  as  all  the  organs  applied  against  it  are  supported,  on  the 
other  side,  by  the  cervical  aponeurosis,  it  follows  that,  when  they 
become  tumefied,  they  project  into  the  mouth  rather  than  beneath 
the  chin. 

From  what  has  preceded  we  may  conclude,  that  wounds  oc- 
curring in  the  sub-maxillary  region  will  in  general  be  more  dan- 
gerous, the  nearer  they  approximate  its  extremities.  In  fact,  a 
pointed  or  cutting  instrument  cannot  penetrate  more  than  a  few 
lines  in  this  direction,  without  danger  of  wounding  the  facial  or 
lingual  arteries,  one  of  the  carotids,  or  the  internal  jugular  vein, 
the  ninth  pair  of  nerves,  par  vagum  or  the  great  sympathetic.  If 
carried  deeper,  the  pharynx  would  be  penetrated.  Upon  the 
median  line,  the  danger  is  much  less,  since  there  are  no  large  ar- 
teries in  this  direction. 

The  order  of  the  superposition  of  the  parts  is  as  follows :  1st, 
the  skin ;  2d,  dense  cellular  tissue  ;  3d,  the  platysma  ;  4th,  lamel- 

hone  into  eleven  distinct  pieces ;  which  he  thus  designates :  the  basi-hyal,  uro-hyal, 
ento-hyal  for  the  body :  the  apo-hyaux  and  crrato-hyavx  for  the  lesser  cornua ;  and 
lastly  the  glosso-hyaux  and  stylhyaux. 


150  OP   THE    NECK. 

lated  cellular  tissue,  in  which  the  superficial  nerves  creep ;  5th. 
the  aponeurosis ;  6th,  the  digastricus,  the  stylo-hyoideus,  mylo- 
hyoideus,  sub-maxillary  gland,  the  facial  artery  and  vein,  lymphatir. 
glands,  a  small  portion  of  the  lingual  artery,  the  submental  artery 
and  the  hypoglo^sal  nerve ;  7th,  the  genio-glossus,  the  duct  of 
Wharton,  the  hyo-glossus,  the  lingual  artery,  gustatory  nerve,  the 
carotids,  internal  jugular,  and  the  nerves  situated  behind  the  latter 
vessels ;  8th,  the  genio-glossus  and  tongue ;  9th,  and  lastly,  the 
mouth  superiorly,  the  pharynx  posteriorly  and  internally. 

Sect.  2.  Infra-Hyoidcan  Region.  (See  plate  3.) 

This  region  is  bounded,  laterally,  by  the  sterno-mastoid  emi- 
nences ;  inferiorly,  by  the  supra-sternal  notch ;  and  superiorly  by 
the  preceding  region.  It  represents  a  pretty  regular  triangle  with 
its  base  turned  upwards.  Upon  the  median  line  we  may  dis- 
cover, by  the  sight  or  touch,  from  above  downwards,  in  the  first 
place,  a  horizontal  semi-circular  depression,  which  corresponds  to 
the  thyro-hyoidean  membrane  ;  next  the  laryngeal  eminence  (po- 
mum  Adami)  formed  by  the  thyroid  cartilage,  and  much  more 
prominent  in  the  adult  man  than  in  women  and  children ;  lower 
down,  an  excavation  which  points  out  the  cryco-thyroid  mem- 
brane ;  next  the  prominence  occasioned  by  the  cricoid  cartilage  ; 
below  this  a  lesser  eminence  which  indicates  the  upper  part  of 
the  trachea,  and  lastly,  the  infra-thyroidal  depression,  which  is 
deeply  excavated  in  those  who  are  emaciated,  superficial  and 
scarcely  perceptible  in  those  of  a  full  habit  of  body. 

In  an  adult  male  of  middle  stature,  the  head  being  slightly 
thrown  back,  the  distance  from  the  os  hyoides  to  the  sternum  is 
six  inches ;  from  the  os  hyoides  to  the  sinus  of  the  thyroid  gland, 
two  inches  and  a  half;  from  the  inferior  margin  of  this  gland  to 
the  sternum,  two  inches  and  a  half  likewise.  At  the  inferior  part 
of  this  region  the  two  sterno-mastoid  muscles  are  only  one  inch 
asunder  ;  at  its  upper  part,  three  inches. 


OF    THE    NECK.  151 


TONSTITUENT  PARTS. 

i.  The  Skin. 

It  presents  the  same  characters  as  in  the  supra-hyoidal  region ; 
only  it  is  still  thinner,  is  destitute  of  hairs,  contains  fewer  sebace- 
ous follicles,  and  is  more  extensible. 

n.  The  Subcutaneous  Layer. 

This  layer  is  likewise  formed  of  three  laminae  arranged  in  the 
same  manner  as  below  the  jaw ;  the  platysma,  however,  leaves 
upon  the  median  line  a  more  open  space,  in  which  the  two  cellular 
sheets  are  so  blended  together  that  they  give  much  greater  density 
to  the  fascia,  which  might  be  called  the  superficial  fascia  of  the 
neck ;  and  we  may  say,  by  way  of  anticipation,  that  the  fascia 
superficialis  exists  upon  all  the  regions  of  the  body ;  only  it  as- 
sumes in  some  parts  fibrous  appearances,  whilst  in  others  it  re- 
mains cellular,  according  to  the  nature  and  functions  of  the  organs 
which  it  covers.  In  this,  for  example,  it  is  thick  and  unyielding 
upon  the  median  line  ;  but  upon  the  sides  it  is  thin  and  less  dis- 
tinct, because  its  laminae  have  separated  in  order  to  embrace  the 
platysma.  Finally,  it  is  in  its  inner  laminae  that  some  nervous  fila- 
ments of  the  cervical  plexus  and  vessels  take  their  course,  among 
which  we  distinguish  the  anterior  jugular  vein,  when  it  exists. 

in.  The  Aponeurosis. 

Continuous,  superiorly,  with  that  of  the  preceding  region,  it 
passes  externally,  into  the  supra-clavicular  region,  arid  is  attach- 
ed, inferiorly,  to  the  sternum  and  clavicle.  Its  external  surface 
is  uniform,  and  in  contact  with  the  fascia  superficialis ;  its  internal 
or  posterior  surface  is  extremely  complicated.  In  order  that  its 
description  may  be  rendered  more  intelligible,  we  will  examine  it 
from  above  downwards  in  the  direction  of  the  median  line,  and 
afterwards  trace  it  from  the  median  line  towards  the  sides. 

From  its  attachment  to  the  os  hyoides,  to  the  upper  part  of  the 
thyroid  gland  it  is  single,  but  then  splits  in  order  to  form  a  sac 


OF    THE    NECK. 

for  this  organ ;  its  two  sheets  afterwards  approximate,  forming 
sheaths  for  the  thyroid  veins,  when  they  again  separate,  and  de- 
scend to  the  upper  part  of  the  sternum  in  order  to  be  attached, 
the  one  to  the  anterior,  the  other  to  the  posterior  surface  of  this 
bone.  This  latter  space  is  filled  only  by  a  laminated  tissue  and 
some  adipose  cells,  and  the  depth  of  the  supra-sternal  excavation 
is  increased  or  diminished  in  proportion  to  the  scarcity  or  abund- 
ance of  these  elements.  Abscesses  forming  in  this  interval  should 
be  opened  early,  lest  they  make  their  way  through  the  posterior 
lamina.  This  posterior  lamina  splits  in  its  turn,  in  order  to  form 
sheaths  for  the  thyroid  vessels,  and  penetrates  into  the  chest, 
where  we  will  find  it  becoming  continuous  with  the  pericardium. 
If  wre  now  trace  the  cervical  aponeurosis  from  the  median  line 
to  each  side,  we  will  perceive  that  it  forms  as  many  sheaths  as 
there  are  muscles,  nerves  and  vessels  ;  that  is  to  say,  when  it  ar- 
rives near  each  of  these  organs,  its  laminae  separate  in  order  to 
envelope  them.  Thus,  for  example,  we  find  a  very  distinct  sheath 
for  the  sterno-hyoideus  muscle  ;  another  for  the  sterno-thyroid  ;  a 
third  for  the  omo-hyoideus  ;  a  fourth,  stronger  than  all  the  others, 
for  the  sterno-mastoid  ;  a  fifth  for  the  carotid  artery ;  a  sixth  for 
the  internal  jugular  vein  ;  in  short,  the  great  sympathetic  nerve, 
the  par  vagum,  thyroid  arteries  and  external  jugular  receive  from 
it  their  several  fibrous  canals.  It  also  envelopes  the  trachea,  pass- 
es behind  the  pharynx,  then  spreads  over  the  anterior  part  of  the 
rectus  anticus  capitis  and  longus  colli  muscles ;  over  the  trans- 
verse processes,  to  which  it  is  attached  ;  embraces  the  scalenus 
anticus,  and  becomes  continuous,  on  the  one  part,  with  the  exter- 
nal sheet,  which  joins  it  behind  the  sterno-mastoid  muscle,  and, 
on  the  other,  with  the  lamellae  of  the  aponeurosis  of  the  supra- 
clavicular  region.  It  is  doubtless  owing  to  this  lamellated  dispo- 
sition of  the  fascia  cervicalis,  that  it  has  seldom  been  described  as 
an  aponeurosis ;  nevertheless,  it  evidently  possesses  a  fibrous  tex- 
ture in  a  great  many  individuals,  especially  in  old  and  thin  sub- 
jects. Besides,  all  anatomists,  as  well  as  surgeons,  have  said  that 
all  the  vessels,  nerves  and  other  organs  which  enter  into  the  com- 
position of  the  cervical  region  are  united  by  a  dense,  extensible 
cellular  tissue,  formed  of  lamellae  more  or  less  intimately  adher- 
ent to  each  other.  It  is  worthy  of  notice  that  fat  is  never  deposit- 
ejl  between  the  numerous  laminae  of  this  fascia,  and  that  it  is 


OF   THE    NECK.  153 

always  external  to  it  that  it  accumulates  in  persons  of  a  gross 
habit. 

It  is  important  to  be  acquainted  with  this  anatomical  arrange- 
ment, as  it  accounts  for  the  rapidity  with  which  abscesses  form 
in  deep-seated  inflammations  of  the  neck,  and,  as  these  inflam- 
mations almost  always  pervade  a  great  extent  of  surface,  it  also 
explains  why  the  pus  burrows  in  various  directions,  without 
rendering  the  integuments  prominent.  It  also  teaches  us  that 
purulent  or  other  collections  should  be  opened  as  soon  as  their 
existence  is  positively  ascertained,  otherwise  they  will  be  very 
liable  to  penetrate  into  the  thorax.  As  the  external  lamina  is 
more  unyielding  than  any  of  the  deeper  seated,  tumours  which 
form  beneath  it  are  disposed  to  take  an  internal  rather  than  an 
external  direction,  and  consequently  may  compress  the  trachea, 
oesophagus,  vessels,  etc.,  in  such  a  manner  as  to  produce  alarm- 
ing symptoms  before  they  present  any  considerable  volume  ex- 
ternally. Finally,  when  we  wish  to  expose  any  organ  in  this 
region,  it  is  absolutely  necessary  to  recollect  the  arrangement  of 
the  cervical  aponeurosis. 

iv.  The  Muscles. 

The  first  which  present  themselves  are  the  sterno-cleido-mas- 
toid  muscles.  These  muscles,  the  internal  margin  of  which 
forms  the  limits  of  this  region,  require  particular  attention  when 
we  perform  the  operation  for  tying  the  carotid.  It  is  their  ante- 
rior border  which  serves  as  a  guide  to  our  incisions  ;  and  as  this 
border  is  thin  and  flattened  out  in  some  subjects,  we  should  keep 
in  mind  the  direction  of  its  fibres,  and  also  recollect  that  it  is 
separated  from  the  other  muscles  by  an  aponeurotic  layer  of 
considerable  thickness ;  for  if  we  do  not,  we  might  fumble  a  long 
time,  and  divide  the  sterno-hyoideus  and  sterno-thyroideus  mus- 
cles, instead  of  simply  drawing  back  the  sterno-mastoideus.  We 
have  frequently  seen  students  thus  perplexed,  in  performing  ope- 
rations upon  the  dead  body. 

Next  come  the  sterno-hyoid  muscles,  which  circumscribe  an 
elongated  triangle,  the  base  of  which  is  inferior.  In  this  space 
we  observe,  under  the  aponeurosis,  and  from  above  downwards ; 
— the  middle  of  the  thyro-hyoid  membrane,  the  angle  of  the  thy- 

20 


154 


OF  THE  IVECK. 


roid  cartilage,  the  crico-thyroid  membrane  and  artery,  the  cricoid 
cartilage,  the  union  of  the  two  lobes  of  the  thyroid  gland,  the 
thyroid  veins  and  the  trachea.  It  is  consequently  in  this  triangle 
that  laryngotomy,  bronchotomy,  etc.,  are  performed.  Enveloped 
in  its  sheath,  the  sterno-mastoid  covers  the  inferior  part  of  the 
sterno-hyoid  muscle,  from  which  it  is  separated  by  the  interven- 
tion of  the  sterno-clavicular  articulation.  The  rest  of  the  external 
surface  of  the  latter  muscle  is  removed  from  the  skin  merely  by 
the  inferior  thyroid  veins,  the  aponeurosis  and  the  subcutaneous 
tissue.  Its  use  being  to  fix  the  os  hyoides  during  the  depression 
of  the  jaw  and  tongue,  or  to  approximate  it  towards  the  thyroid 
cartilage,  it  should  not  be  cut  across  in  operations.  Its  inferior 
half  only  rests  upon  the  sterno-thyroideus ;  it  next  passes  beyond 
it  towards  the  median  line,  and  then  immediately  covers  the 
thyroid  gland,  the  cartilages  of  the  larynx  and  the  thyro-hyoid 
excavation. 

The  next  muscle  is  the  sterno-thyroideus,  which  is  a  little 
broader  than  the  preceding,  behind  which  it  is  placed,  and,  with 
its  fellow,  circumscribes  another  elongated  triangle,  W7ith  its  base 
directed  upwrards.  In  this  triangle  we  observe  the  same  parts 
as  pointed  out  in  the  former,  with  the  addition  of  a  portion  of 
the  sterno-hyoid  muscle  superiorly.  The  external  surface  of  the 
sterno-thyroideus  muscle  is  crossed,  superiorly,  by  the  horizontal 
branch  of  the  superior  thyroid  artery ;  the  anastomosis  of  the 
ramus  descendens  noni,  and  the  small  plexus  which  it  gives  off, 
pass  over  it  inferiorly,  and  glide  between  it  and  the  preceding 
muscle.  This  muscle  rests  from  below  upwards  upon  the  thy- 
roidal  venous  plexus  and  the  carotid,  upon  the  thyroid  gland, 
jts  arteries,  and  the  thyroid  cartilage  into  which  it  is  inserted. 
It  also  corresponds  more  or  less  remotely  to  the  trachea,  cesoph- 
agus,  recurrent  nerves,  etc.  The  two  sterno-thyroid  muscles 
are  about  one  inch  asunder  in  the  middle  of  the  region,  and  this 
distance  diminishes  or  increases  in  proportion  as  they  approxi- 
mate to  the  apex  or  the  base  of  the  triangle. 

In  the  fourth  place,  we  find  the  anterior  portion  of  the  omo- 
hyoideus,  covered,  at  the  moment  it  emerges  from  beneath  the 
sterno-mastoid,  by  the  anterior  jugular  vein  and  a  branch  of  the 
superior  thyroid  artery.  It  is  enveloped  by  the  fascia  cervica- 
lis  and  is  separated  fromt  he  skin  by  some  filaments  of  the  cervical 


OF   THE    NECK.  155 

plexus  and  the  subcutaneous  tissue  ;  being  readily  felt  through  the 
integuments  in  some  individuals.  As  it  ascends  towards  the  os 
hyoides  it  crosses  the  internal  jugular  vein,  the  carotid,  the  great 
sympathetic,  par  vagum,  and  descendens  noni,  the  superior  thy- 
roid artery,  the  thyro-hyoideus  muscle,  the  membrane  of  this 
name,  and,  lastly,  the  muscles  which  have  just  been  examined. 

The  omo-hyoideus  assists  in  forming  two  triangles  with  which 
the  surgeon  should  be  well  acquainted. 

The  first  is  superior,  and  is  bounded  superiorly  by  the  supra- 
hyoidean  region ;  externally,  by  the  sterno-mastoideus  muscle  ; 
inferiorly  and  internally,  by  the  omo-hyoideus.  In  this  triangle, 
which  we  call  omo-hyoidien,  we  find  the  following  organs :  the  in- 
ternal jugular  and  the  trunks  of  the  lingual  and  facial  veins,  the 
ramus  descendens  noni,  par  vagum,  superior  laryngeal  nerve,  the 
great  sympathetic,  and  about  one  inch  of  the  primitive  carotid ; 
then  the  origin  of  the  external  and  internal  carotids,  that  of  the 
facial,  lingual,  occipital  and  sometimes  inferior  pharyngeal  arte- 
ries ;  the  superior  thyroid  artery  is  always  found  in  it,  and  may 
here  be  readily  exposed  and  tied,  as  we  will  mention  directly : 
finally,  the  hyo-thyroideus  muscle,  a  small  portion  of  the  inferior 
and  middle  constrictors,  the  thyroid  cartilage,  its  superior  cornu, 
and  the  side  of  the  hyo-thyroid  membrane. 

The  second,  we  call  the  omo-tracheal  triangle,  which  is  much 
more  extensive  than  the  former,  and  bounded  superiorly  and  ex- 
ternally, by  the  omo-hyoideus  muscle,  externally  and  inferiorly 
by  the  sterno-mastoideus,  and  internally  by  the  trachea.  In  it  we 
observe,  the  whole  of  the  sterno-hyoid  and  thyroid  muscles,  a 
small  portion  of  the  thyro-hyoideus,  one  lobe  of  the  thyroid  gland, 
the  arteries  which  are  distributed  to  it,  the  sub-hyoidean  veins, 
the  plexus  of  the  ninth  pair  of  nerves,  the  side  of  the  cricoid  car- 
tilage, of  the  trachea  and  oesophagus,  the  recurrent  nerve,  primi- 
tive carotid,  inferior  thyroid  artery,  the  great  sympathetic  and  par 
vagum,  the  internal  and  anterior  jugulars,  lastly  the  vertebral 
artery. 

The  hyo-thyroidei  (thyro-hyoidiens)  are  the  last  superficial  mus- 
cles which  we  find  in  this  region ;  they  are  covered  by  all  the 
others,  resting  directly  upon  the  thyroid  cartilage,  but  separated 
considerably  from  the  thyro-hyoid  membrane.  It  is  behind  their 
posterior  margin  that  the  superior  laryngeal  nerve  insinuates  itself 


15(3  or  THI;  IVECK. 

between  the  os  hyoides  and  thyroid  cartilage  before  it  penetrate* 
into  the  larynx. 

The  longus  colli  and  a  portion  of  the  rectus  anticus  capitis  ma- 
jor, deeply  situated  upon  the  transverse  processes  and  bodies  of 
the  cervical  vertebrae,  also  appertain  to  the  infra-hyoidean  region. 
Between  the  former  and  the  scaleni  there  is  a  triangle  through 
which  the  vertebral  artery  runs  in  its  course  to  the  foramina  of 
the  transverse  processes. 

v.  The  Arteries. 

They  are  numerous  and  very  important,  the  carotid  arteries 
especially. 

The  right  carotid  is  shorter,  nearer  the  median  line,  more  an- 
terior and  thicker  than  the  left ;  which  is  owing  to  its  being  given 
off  by  the  brachio-cephalic  trunk.  This  disposition  affords  an 
additional  reason  for  not  performing  oesophogatomy  on  this  side, 
for  not  applying  a  ligature  upon  the  artery  too  near  the  inferior 
part  of  the  neck,  and  for  taking  suitable  precautions  in  the  opera- 
tion of  tracheotomy.  Anteriorly,  the  left  carotid  is  in  the  first 
place  separated  from  the  sternal  portion  of  the  sterno-mastoid 
muscle  by  a  space  of  about  an  inch  in  extent,  which  is  filled  with 
cellular  tissue,  fat,  veins  of  considerable  size,  some  descending 
branches  of  the  cervical  plexus,  etc.  On  the  right,  this  interval  is 
less  extensive,  and  the  artery  runs  nearer  the  anterior  margin  of 
the  muscle.  Both  of  the  vessels  are  next  covered  by  the  internal 
surface  of  this  same  muscle,  by  the  posterior  margin  of  the  sterno 
thyroideus,and  the  omo-hyoideus,which  crosses  them;  by  the  ramus 
descendens  norii,  which  sometimes  rests  upon  the  arterial  sheath, 
by  the  thyroid  gland  itself,  whenever  it  is  a  little  developed,  and 
indirectly  by  the  cervical  aponeurosis,  the  subcutaneous  layer  and 
skin.  But  as  the  sterno-mastoid  muscle  directs  its  course  ob- 
liquely upwards  and  backwards,  it  consequently  follows  that  the 
carotid  becomes  more  superficial  the  higher  it  ascends  and  there- 
fore more  easy  of  access.  Posteriorly,  it  rests  upon  the  great 
sympathetic,  upon  the  cardiac  filaments  of  this  nerve  and  the  par 
vagum,  which  are,  as  it  were,  glued  to  its  sheath  ;  upon  the  infe- 
rior thyroid  artery,  opposite  the  omo-hyoideus  muscle  or  a  little 
lower  down ;  upon  the  ascending  cervical  and  vertebral  arteries, 


OP    THE    NECK.  157 

and  the  accompanying  vein  of  the  latter ;  and  lastly,  immediately 
upon  the  anterior  part  of  the  base  of  the  cervical  transverse  pro- 
cesses and  of  the  triangle  limited  by  the  anterior  scalenus  and 
longus  colli  muscles. 

From  these  relations  of  the  carotid  posteriorly  it  follows  that  it 
might  be  compressed  efficaciously  on  the  left  side,  whilst  waiting 
for  the  application  of  a  ligature,  in  case  it  should  be  opened  some 
distance  above  the  sternum.  It  should  always  be  remembered, 
however,  that  the  nerves  cannot  long  sustain  this  pressure. 

Externally  it  is  coasted  by  the  par  vagum,  then  by  the  jugular 
vein  and  phrenic  nerve  ;  inferiorly  by  the  trunk  of  the  ascend- 
ing cervical  artery,  b)^  that  of  the  inferior  thyroid,  the  cervical 
plexus  and  the  parts  which  constitute  the  supra-clavicular  region. 
Internally,  it  touches,  in  several  points,  the  inferior  and  middle 
constrictors  of  the  pharynx,  the  trachea  on  the  right,  and  the 
oesophagus  on  the  left ;  from  which  parts  it  is  separated  only  by 
some  dense  and  lamellated  cellular  tissue,  the  recurrent  nerve, 
diverse  filaments  of  the  sympathetic  and  by  the  inferior  thyroid 
artery ;  so  that  near  the  sternum  the  two  carotids  are  removed 
from  each  other  only  by  the  trachea,  that  is  to  say,  by  an  interval 
of  about  an  inch  or  eighteen  lines.  Superiorly,  on  the  contrary, 
they  are  separated  by  the  entire  thickness  of  the  larynx. 

From  these  anatomical  dispositions  it  follows  that  if  we  wish 
to  cut  down  to  the  external  side  of  the  carotid  artery,  we  can 
only  do  it  in  its  inferior  third,  behind  the  sterno-mastoid  muscle  ; 
its  anterior  side,  however,  may  be  exposed  throughout  its  whole 
extent.  In  the  first  direction,  an  instrument  could  not  reach  it 
without  having  previously  divided  the  internal  jugular  vein ;  in 
the  second,  on  the  contrary,  there  are  no  important  vessels  be- 
fore it.  Therefore,  whenever  we  wish  to  apply  a  ligature  on  this 
artery,  we  should  endeavor  to  fall  upon  its  anterior  part,  and  the 
following  are  the  organs  which  the  instrument  must  then  tra- 
verse :  1st.  the  skin,  parallel  to  the  sterno-mastoid,  but  in  such  a 
manner  that,  at  the  upper  part,  the  incision  should  pass  on  the 
inner  side  of  the  muscular  margin,  whilst  at  the  lower  part,  it  is 
better  to  make  it  a  little  more  externally,  on  account  of  the  di- 
rection of  the  artery :  this  remark,  however,  is  strictly  applicable 
to  the  left  side  only;  2d.  the  aponeurosis,  forming  a  double  lamina 
before  and  behind  this  muscle,  which  must  be  drawn  outwards 


158  OF   THE    NECK. 

after  the  division  of  this  fascia  ;  3d.  a  thinner  but  very  extensible 
fibrous  lamina,  which  passes  from  the  sterno-hyoid  and  thyroid 
muscles,  as  well  as  from  the  trachea,  anterior  to  the  vessels,  in 
order  to  blend  itself  externally  with  the  deep  lamina  of  the 
sterno-mastoid  muscle.  In  this  lamina  we  usually  find  some  fila- 
ments of  the  cervical  plexus  and  the  descendens  noni :  it  is  this 
which  gives  a  sheath  to  the  omo-hyoideus,  a  muscle  which  we  are 
sometimes  obliged  to  divide,  and  which  always  crosses  the  caro- 
tid in  such  a  manner,  that  when  we  tie  this  artery  in  the  orno- 
hyoidean  triangle,  we  should  depress  it  inwards,  and  when  in  the 
omo-tracheal  triangle,  we  must  draw  it  upwards  and  outwards  ; 
in  this  manner  we  may  generally  dispense  with  cutting  this  small 
muscle  across ;  4th.  the  sheath  which  the  aponeurosis  gives  to  the 
artery,  the  opening  of  which  is  one  of  the  most  delicate  steps  of 
the  operation ;  for  if  we  cut  too  much  outwards,  the  internal 
jugular  vein  may  be  wounded  ;  if  we  incise  directly  upon  the 
artery,  we  might  open  this  vessel  itself.  Nevertheless,  if  this 
sheath  is  not  divided,  we  will  almost  inevitably  include  in  the 
ligature,  together  with  the  carotid,  both  the  descendens  noni  and 
the  cardiac  nerves,  which  are  more  or  less  adherent  to  its  outer 
surface.  For  this  reason,  after  having  separated  the  artery  from 
the  vein,  we  should  seize  this  fibrous  canal  upon  the  former  with 
the  forceps,  and  then  make  a  small  horizontal  incision  into  it,  in 
the  same  way  as  we  would  open  a  hernial  sac.  Afterwards  it 
will  be  easy  to  dilate  this  opening  as  much  as  is  necessary,  by 
means  of  a  director  introduced  between  the  aponeurosis  and  the 
vessel.  In  this  manner  the  artery  alone  will  be  isolated,  all  the 
nerves  avoided,  and  the  consequences  of  the  operation  rendered 
less  formidable. 

Whenever  we  wish  to  secure  the  primitive  carotid,  whether  for 
an  aneurism,  a  wound,  or  any  disease  of  its  branches  whatsoever, 
the  omo-hyoidean  triangle  is  to  be  preferred,  because  it  affords  us 
the  most  room,  and  the  vessels  are  more  superficial.  But  wrhen 
the  aneurism  occupies  the  trunk,  we  are  obliged  to  place  the  lig- 
ature nearer  the  sternum ;  in  which  case  the  operation  is  more 
easily  performed  on  the  right,  but  it  is  likewise  more  dangerous, 
because  the  proximity  of  the  subclavian  will  hinder  the  formation 
of  the  clot  in  the  origin  of  the  carotid. 

The  common  carotid  divides  opposite  to  the  superior  margin 


OF   THE    NECK.  159 

of  the  thyroid  cartilage,  on  a  level  with  the  inferior  part  of  the 
third  cervical  vertebra ;  so  that  the  infra-hyoidean  region  includes 
about  an  inch  of  the  internal  and  external  carotids.  These  two 
branches  present  the  same  general  relations  as  the  trunk  from 
which  they  originate.  The  external,  which  might  here  be  better 
called  the  superficial,  is  placed  before  and  even  a  little  within  the 
internal,  which  is  the  largest  and  is  situated  upon  the  anterior 
part  of  the  spine.  A  ligature  ought  not  to  be  applied  on  these 
two  branches  so  near  their  origin.  In  cases  which  might  seem 
to  demand  it,  the  ligature  of  the  common  trunk  should  always 
be  preferred. 

Before  the  external  carotid  enters  the  supra-hyoidean  region 
it  generally  gives  off  the  superior  thyroid,  the  external  maxillary, 
the  lingual  and  the  pharyngeal  arteries. 

The  superior  thyroid  is  the  most  important  in  a  surgical  point 
of  view.  The  peculiarities  relative  to  the  other  branches  were 
pointed  out  in  the  submaxillary  region.  This  branch  separates 
from  the  trunk  on  a  level  with  or  a  little  below  the  cornu  of  the 
os  hyoides,  and  takes  a  tortuous,  but  generally  oblique  direction 
downwards  and  forwards,  in  order  to  arrive  at  the  superior  and 
external  part  of  the  thyroid  gland.  Enveloped  in  the  deep 
laminae  of  the  fascia  cervicalis,  it  is  covered  a  little  by  the  sterno- 
mastoid  muscle,  by  some  cellular  tissue,  the  aponeurosis  of  the 
neck,  the  subcutaneous  layer,  and  the  skin  ;  it  is  crossed  by  the 
descendens  noni :  posterior  to  it  we  find  the  superior  laryngeal 
nerve  and  numerous  filaments  of  the  great  sympathetic.  In  this 
tract  the  superior  thyroid  artery  gives  off  a  branch  which  runs 
along  the  inferior  border  of  the  os  hyoides,  and  is  distributed  to 
the  thyro-hyoid  membrane :  this  may  be  wounded  from  attempts 
at  suicide.  It  also  sends  off  a  second  branch  which  descends 
behind  the  gland,  upon  the  inner  and  anterior  part  of  the  caro- 
tideal  sheath.  This  branch  must  be  pressed  towards  the  trachea, 
if  the  principal  artery  of  the  neck  should  be  tied  at  this  point.  A 
third  branch  is  the  laryngeal,  which  runs  between  the  constric- 
tors and  the  posterior  margin  of  the  thyro-hyoideus  muscle,  upon 
the  membrane  of  this  last  name,  perforates  it,  and  is  lost  in  the 
larynx.  Here,  the  thyroid  artery  next  distributes  numerous  large 
branches  to  the  gland,  which  in  their  turn  give  off  a  certain 
number  of  twigs,  among  which  the  crico-thyroideal  in  particular 


160 


OF    THE    NECK. 


deserves  notice,  and  will  be  examined  when  we  come  to  treat  of 
the  larynx  and  trachea.  All  these  arteries  ramify  in  the  glandular 
tissue,  inosculate  with  their  fellows  of  the  opposite  side,  with 
branches  of  the  inferior  thyroid,  and  thereby  form  in  this  organ 
an  exuberant  plexus,  which  may  occasion  profuse  haemorrhage, 
notwithstanding  the  carotids  have  not  been  wounded.  Indeed, 
we  are  of  opinion,  without  doubting  the  sincerity  of  authors  who 
have  mentioned  that  haemorrhages  proceeding  from  wounds  of 
the  internal,  external,  or  common  carotids,  have  been  arrested 
without  the  application  of  ligatures,  that  such  cases  should  be 
considered  as  divisions  of  the  thyroid  artery  or  its  branches,  or 
of  the  facial,  lingual  arteries,  etc. 

According  to  the  disposition  of  the  trunk  of  the  superior  thy- 
roid artery,  it  might  be  readily  exposed  and  tied,  either  in  the 
direction  of  a  line  drawn  from  the  cornu  of  the  os  hyoides  to 
the  anterior  and  inferior  part  of  the  thyroid  cartilage,  or  by 
making  an  incision  obliquely  downwards  and  outwards,  from  the 
os  hyoides  to  the  sterno-mastoid  muscle ;  or,  lastly,  by  dividing 
the  parts  in  the  omo-hyoid  triangle  parallel  to  the  sterno-mastoid 
muscle.  In  this  space,  in  fact,  the  artery,  before  it  reaches  the 
gland,  is  covered  only  by  the  ramus  descendens  noni,  some 
veins,  the  aponeurosis,  and  the  common  integuments. 

We  likewise  find  in  this  region  two  other  considerable  arte- 
ries ;  the  inferior  thyroid  and  the  vertebral.  The  inferior  thyroid 
is  at  first  situated  behind  the  common  carotid  and  internal  jugular, 
the  par  vagum  and  great  sympathetic  nerves,  and  before  the  sca- 
lenus  anticus  and  longus  colli  muscles ;  it  then  ascends  in  a  ser- 
pentine manner,  behind  the  inferior  part  of  each  of  the  lobes  of 
the  thyroid  gland,  where  it  terminates  in  a  great  number  of 
branches  which  anastomose  with  those  of  the  opposite  side,  and 
the  superior  thyroid.  When  the  left  thyroid  artery  insinuates 
itself  behind  the  carotid  very  low  down,  it  may  be  posterior  to  the 
thoracic  duct ;  at  the  same  time  it  is  nearer  the  oesophagus  than 
the  right.  Anteriorly  and  externally  it  is  crossed  by  the  cervical 
branch  of  the  lingual  nerve  (descendens  noni) ;  the  inferior  la- 
ryngeal  nerve  (recurrent),  on  the  contrary,  is  situated  internally 
and  posteriorly.  The  inferior  thyroid  artery  is  almost  always  met 
with  in  the  summit  of  the  omo-tracheal  triangle,  in  the  direction 
of  the  omo-hyoideus  muscle,  behind  which  it  is  also  sometimes 


OF   THE    NECK. 


161 


directly  situated ;  a  circumstance  important  to  recollect  when  we 
wish  to  tie  this  vessel.  This  operation  might  be  performed  with- 
out difficulty  by  following  the  method  recommended  for  the  caro- 
tid ;  only,  instead  of  opening  the  sheath  of  the  latter,  we  should 
push  it  outwards,  whilst  we  detach  inwards  the  thyroid  gland  and 
trachea,  and  draw  the  omo-hyoideus  muscle  upwards.  The  ar- 
tery will  always  be  found  a  few  lines  higher  or  lower  in  this 
space,  quite  near  the  fleshy  bundle.  In  applying  the  ligature,  we 
must  exclude  the  two  principal  nerves  which  pass  before  and  be- 
hind the  vessel ;  consequently,  wre  must  vary  the  method  accord- 
ing to  the  position  of  the  parts ;  if  the  nervous  trunks  are  very 
close  to  the  trachea,  the  needle  must  be  passed  from  below  up- 
wards and  from  within  outwards  ;  if  these  nerves  are  nearer  the 
carotid,  we  should  pass  it  in  the  opposite  direction. 

The  ligature  of  the  inferior  and  superior  thyroid  arteries  is  an 
operation  which  might  be  frequently  performed,  either  on  ac- 
count of  a  wound  of  these  vessels,  or  with  the  view  of  causing 
atrophy  of  the  thyroid  gland  in  bronchocele  ;  or  finally,  for  the 
purpose  of  enabling  us  to  extirpate  the  thyroid  body  itself;  which 
has  already  been  done  by  several  skilful  surgeons,  and  especially 
by  the  celebrated  Walther  of  Bonn.  But  it  is  necessary  to  re- 
collect that  a  fifth  thyroid  artery  sometimes  exists  in  the  direction 
of  the  median  line. 

We  have  occasionally  met  with  this  branch,  which  was  first 
described  by  Neubauer  in  1772,  and  since  by  almost  all  correct 
anatomists.  It  sometimes  arises  from  the  arteria  innominata,  but 
more  frequently  from  the  arch  of  the  aorta  ;  it  then  ascends  in  a 
more  or  less  tortuous  manner  towards  the  inferior  part  of  the 
thyroid  gland,  anterior  to  the  trachea,  covered  by  the  thyroid 
veins,  the  aponeurosis  and  the  skin.  The  existence  of  this  artery 
would  render  tracheotomy  very  dangerous,  and  it  would  be  diffi- 
cult to  apply  a  ligature  around  it  on  account  of  the  very  large 
veins  which  commonly  run  before  it.  It  is  also  well  to  know 
that  the  thyroid  arteries  vary  much  in  volume,  position  and  even 
in  number  ;  and  we  should  especially  recollect  that  variety,  des- 
cribed by  F.  M eckel,  in  which  the  thyroid  of  Neubauer  originated 
from  the  brachio-cephalic  trunk,  and  passed  to  the  left  lobe  of  the 
gland,  crossing  the  anterior  surface  of  the  trachea ;  so  that  it 
would  have  been  impossible  to  avoid  wounding  this  vessel,  if  an 


10^  OF    T1JE 

opening  had  been  made  into  the  air  tube.  According  to  M. 
Meckel,  Burns  has  met  with  the  same  anomaly ;  but  we  have  not 
been  able  to  discover  this  fact  in  the  work  of  the  latter  author. 

The  second  or  vertebral  artery  also  originates  from  the  subcla- 
vian  :  it  is  situated  behind  the  internal  jugular  and  carotid  artery, 
and  crosses  them  very  obliquely  from  without  inwards  and  from 
below  upwards,  in  its  course  to  the  infra-hyoidean  region ; 
so  that  in  some  subjects  it  inclines  a  little  within  the  common 
carotid.  The  great  sympathetic  and  eighth  pair  cross  it  in  the 
same  direction,  so  that  inferiorly  these  nerves  are  on  the  inner 
side,  whilst  superiorly  they  are  on  the  outer  side  of  the  artery. 
On  its  inner  side,  it  is  in  relation  with  the  longus  colli  muscle, 
then  with  the  inferior  laryngeal  nerve,  the  oesophagus  and 
trachea;  on  its  outer  side,  with  the  middle  cervical  ganglion  and 
the  filaments  detached  from  it,  with  the  phrenic  nerve  and  scalenus 
anticus  muscle  ;  finally,  it  enters  the  canal  in  the  transverse  cervi- 
cal processes,  and  passes  on  to  the  cranium. 

vi.  The  Veins. 

They  are  numerous  and  important  in  the  infra-hyoidean  re- 
gion ;  the  most  conspicuous  are, 

(a)  The  Internal  Jugular.  This  vein  is  situated  on  the  outer 
side  of  the  carotid  artery,  and  accompanies  it.  They  are  both  en- 
veloped by  a  common  fibro-cellular  sheath,  but  have  nevertheless 
each  a  distinct  envelope.  We  distinguish  the  vein  from  the  artery 
by  the  tenuity  of  its  coats,  wrhich  collapse,  and  are  almost  transpa- 
rent ;  by  its  external  position,  and  by  the  colour  of  its  blood- 

Upon  the  dead  body,  the  internal  jugular  vein  is  generally  flat- 
tened in  such  a  manner  as  to  form  a  semi-canal  applied  upon  the 
external  half  of  the  carotid  artery.  Upon  the  living,  its  relative 
volume  is  much  greater,  so  that  it  covers  a  considerable  portion 
of  the  anterior  surface  of  the  artery,  and  its  dimensions  increase 
on  expiration  and  diminish  on  inspiration.  Hence  it  follows  that 
the  size  of  the  internal  jugular  vein  will  be  augmented,  during  the 
performance  of  certain  operations,  in  proportion  to  the  degree  in 
which  respiration  is  impeded :  therefore  at  such  times  we  should 
endeavour  to  calm  the  agitation  of  the  patient,  and  induce  him  to 
make  full  inspirations.  It  is  especially  during  the  application 


OP    THE    NECK.  163 

of  the  ligature  of  the  carotid  that  this  alternate  dilatation  and  col- 
lapse greatly  embarrass  the  operator.  It  is  true  that  we  might 
possibly  prevent  this,  by  compressing  the  vein  above  the  place 
where  we  wish  to  lay  bare  the  artery.  The  internal  jugular  vein 
is  covered  anteriorly  by  the  parts  which  conceal  the  primitive 
carotid ;  only,  as  it  is  more  external,  the  sterno-mastoid  muscle 
covers  it  to  a  much  greater  extent ;  on  the  outer  side  of  the  vein 
are  situated  the  phrenic  nerve  and  the  cervical  plexus  in  general ; 
internally,  it  touches  the  carotid  artery,  and  is  sometimes,  as  it 
were,  even  adherent  to  it ;  posteriorly,  it  crosses  the  inferior 
thyroid  artery  below,  and  the  nervous  filaments  of  the  cervical 
plexus,  which  anastomose  with  the  great  sympathetic,  above.  In 
the  latter  direction  it  usually  covers  the  ascending  cervical  arte- 
ry, and  rests  upon  the  internal  side  of  the  scalenus  anticus.  It  is 
between  its  internal  posterior  part  and  the  carotid  that  the  par 
vagum  and  great  sympathetic  are  situated ;  so  that  in  order  to 
avoid  wounding  these  nerves  when  we  are  trying  to  isolate  the 
vein,  the  needle  should  be  introduced  on  the  outer  side  of  the 
artery.  Where  the  jugular  empties  into  the  subclavian  vein,  it 
generally  conceals  the  vertebral  artery.  Its  anterior  part  receives 
a  great  number  of  veins,  which  cross  the  common  carotid,  and 
may  thereby  cause  considerable  perplexity  when  we  attempt  to 
apply  a  ligature  around  this  artery;  and  these  veins  are  the  more 
annoying  on  account  of  their  irregularity,  in  relation  to  num- 
ber, magnitude  and  position.  Be  this  as  it  may,  all  these  venous 
branches  appertain  to  the  organs  which  constitute  the  supra  and 
sub-hyoidean  regions,  and  are  particularly  congregated  below  the 
cornu  of  the  os  hyoides,  on  the  one  part,  and  at  the  inferior  part 
of  the  region,  above  the  sterno-clavicular  articulation,  on  the 
other.  We  may  also  state  that  some  venous  ramusculi,  of  a  cer- 
tain calibre,  from  the  supra-cavicular  region  and  anterior  part  of 
the  chest,  often  pass  through  the  latter  point,  especially  on  the 
left  side,  in  their  course  to  the  subclavian  or  internal  jugular. 

When  this  disposition  exists,  a  more  or  less  complicated  plexus 
is  the  result,  which  might  increase  the  difficulties  of  tying  the 
subclavian  artery  within  the  sterno-mastoid  muscle.*  It  also 
follows  from  this  arrangement  that,  in  order  to  avoid  these  veins. 

•  Langenbeck,  loco  citat. 


164  OF    THE    NECK. 

when  we  seek  for  the  carotid,  it  is  much  better  to  lay  it  bare  either 
immediately  above  or  below  the  omo-hyoideus  muscle. 

(  b  )  The  cxternalJugular  Vein  usually  appertains  to  the  supra- 
clavicular  region,  where  we  will  examine  it ;  sometimes,  however. 
wre  find  it  in  the  sub-hyoidean  region,  or  it  may  exist  there  at  the 
same  time  that  another  is  situated  in  the  usual  position.  In  this 
case,  it  is  generally  smaller,  and  the  other  bears  the  name  of  ante- 
rior jugular.  We  have  sometimes  found  the  anterior  jugular  with 
the  external,  and  we  have  met  with  it  single,  upon  the  dead  body, 
three  different  times.  The  anterior  jugular  vein  sometimes  re- 
ceives the  greater  portion  of  the  branches  of  the  face  and  sub- 
maxillary  region ;  at  other  times  it  appears  to  be  formed  solely 
of  some  thyroid  branches  which  have  deviated  from  their  natural 
direction.  Its  trunk  sometimes  opens  near  the  larynx,  in  the  in- 
ternal jugular ;  more  frequently  it  descends  singly  to  the  inferior 
part  of  the  neck,  and  then  empties  into  the  same  vessel ;  and 
again  it  proceeds  directly  to  the  subclavian,  especially  on  the  left 
side.  In  some  subjects  this  vein  is  very  large,  and  might  be 
opened  with  equal  facility  and  in  the  same  manner  as  the  external, 
if  thought  necessary. 

In  general,  when  it  supplies  the  place  of  the  external  jugular, 
it  lies  superficially  upon  the  aponeurosis  ;  at  other  times,  it  runs 
between  the  muscles  and  the  fascia  cervicalis  which  it  traverses, 
especially  when  it  comes  from  the  thyroid  gland.  It  is  on  this 
account,  that,  when  we  operate  upon  the  deep-seated  organs,  we 
should  divide  the  tissues  cautiously,  in  order  that  we  may  tie  or 
push  it  aside,  if  wre  are  unwilling  to  divide  it. 

(  c  )  The  Thyroid  Veins.  They  are  proportionately  larger  in 
children  than  adults,  in  the  female  than  the  male ;  and  their 
volume  is  generally  in  a  direct  ratio  to  that  of  the  gland.  They 
may  be  arranged  under  two  orders :  those  which  follow  the  di- 
rection of  their  collateral  arteries,  are  a  little  more  superficial, 
and  cross  the  carotids  anteriorly,  in  order  to  terminate  in  the  in- 
ternal jugular  vein :  the  others  collect  below  the  gland,  forming 
three,  four,  or  five  principal  branches,  which  descend  before  the 
trachea,  where  they  constitute  a  species  of  plexus  between  the 
sterno-thyroid  and  sterno-hyoid  muscles.  It  is  this  sub-thyroidean 
plexus  which  renders  tracheotomy  dangerous,  because  it  is  difficult 
to  avoid  all  these  veins,  and  consequently  haemorrhage.  It  is 


OF   THE   NECJC.  165 

enveloped  in  a  lamellated  cellular  tissue,  and  its  branches  empty 
into  the  subclavians  as  they  approximate  the  trachea.  It  is  proper 
to  observe  that  it  would  be  more  easy  to  reach  the  trachea,  with- 
out wounding  these  veins,  in  the  vicinity  of  the  sternum,  than 
immediately  below  the  thyroid  gland,  because  in  the  former  situa- 
tion these  vessels  run  in  a  parallel  direction,  whilst,  in  the  latter, 
they  intersect  one  another  in  divers  manners.  Furthermore, 
they  lie  beneath  the  aponeurosis ;  so  that  they  cannot  be  distin- 
guished through  the  skin,  even  when  they  are  in  a  varicose  state. 
(  d  )  The  other  veins  of  the  infra-hyoidean  region  empty  into 
one  of  the  preceding  branches,  and  do  not  require  further  consid- 
eration. The  facial  and  lingual  veins  also  descend  into  this 
region,  and  are  found  below  the  great  cornu  of  the  os  hyoides ; 
but  they  form  a  part  of  those  which  cross  the  carotid  artery 
superiorly,  and  which  were  pointed  out  in  the  commencement  of 
this  paragraph. 

vn.  The  Lymphatics. 

These  vessels  are  numerous  and  pretty  well  understood ;  some 
of  them  descend  into  the  glands  of  the  mediastinum  ;  others  into 
those  of  the  axilla ;  but  the  greater  number  terminate  under  the 
sterno-mastoid  muscle. 

It  is  very  necessary  to  have  a  correct  knowledge  of  the  glands 
of  this  region,  on  account  of  the  variety  of  diseases  to  which  they 
are  subject.  In  the  first  place,  they  form  a  very  remarkable  chain 
around  the  internal  carotid  and  internal  jugular;  there  are  also 
some  others  of  smaller  size  behind  the  sub-thyroidean  plexus, 
upon  the  anterior  part  of  the  trachea,  and  lastly  we  sometimes 
find  one  of  them  upon  the  fore  part  of  the  larynx.* 

When  these  glands  become  tumefied,  they  may  be  mistaken  for 
other  affections.  Thus,  the  slow  and  gradual  developement  of  one 
of  those  in  the  carotideal  groove,  may  lead  to  the  supposition  that 
an  aneurism  of  the  carotid,  of  one  of  its  branches,  or  of  the  inferior 
thyroid  exists.  This  mistake  may  easily  be  made  in  consequence 
of  the  enlarged  gland  being  firmly  compressed,  by  the  laminae  of 
the  cervical  aponeurosis  and  the  sterno-mastoideus  muscle,  against 
the  artery  situated  behind  it,  whereby  a  pulsatory  motion  is  trans- 
mitted to  the  tumour. 

*Burns. 


160 


OF    THE    NECK. 


Tiiose  situated  before  the  trachea  may  be  mistaken  ior  aa 
enlargement  of  the  thyroid  gland,  and  we  are  of  opinion  that  this 
organ  is  said  to  have  been  removed  more  than  once,  when  one  of 
the  surrounding  lymphatic  glands  merely  was  extirpated.  Be  this 
as  it  may,  as  they  correspond  to  the  aponeurosis  in  those  places 
where  it  is  thickest,  they  will,  as  they  enlarge,  compress  the 
trachea  and  oesophagus,  and  by  suspending  respiration  and  degluti- 
tion produce  alarming  consequences. 

The  gland  described  by  Burns  may  also  become  greatly  en- 
larged ;  as  has  occurred  to  this  author's  notice  ;  and  may  thereby 
lead  to  numerous  errors,  and  occasion  unpleasant  results. 

Lastly,  we  find  some  very  small  absorbent  glands,  between  the 
oesophagus  and  trachea,  around  the  recurrent  nerves.  Should 
these  become  diseased,  it  would  be  much  more  difficult,  on  account 
of  their  depth,  to  form  our  diagnosis,  than  in  the  preceding  cases. 

vni.  The  Nerves. 

The  nerves  of  this  region  are  very  numerous,  and  merit  much 
attention. 

(  a  )  From  the  cervical  plexus,  it  derives  both  superficial  and 
deep-seated  nerves. 

The  former  appertain  to  the  filaments  which  ascend  before 
the  larynx  and  under  the  chin,  between  the  aponeurosis  and  the 

platysma.  They  are  flattened,  hard,  and  appear  to  preside  over 
sensation.  These  branches  would  necessarily  be  divided  when 
a  ligature  is  applied  around  the  carotid  in  the  omo-hyoidean  trian- 
gle. Their  inosculations  with  the  facial  account  for  the  pain, 
sometimes  very  acute,  which  subcutaneous  tumours  of  the  neck 
give  rise  to  in  the  face. 

The  latter  are  filaments  of  communication  with  the  great  sym- 
pathetic, etc.,  and  especially  the  branch  which  anastomoses  in  the 
form  of  a  loop  with  the  descendens  noni.  As  this  branch  comes 
out  from  beneath  the  sterno-mastoid,  it  crosses  the  anterior  part 
of  the  jugular  vein  very  obliquely,  before  it  unites  with  the  filament 
of  the  ninth  pair.  The  other  branches  of  the  cervical  plexus  pass 
behind  the  deep  vessels  of  the  neck. 

(  b  )  We  next  find  the  ramus  descendens  noni.  It  separates 
from  the  trunk  or  hypo-glossal  nerve  as  high  up  as  the  os  hyoides, 
and  runs  first  on  the  outer  side  of  the  internal  carotid,  afterwards 


OP    THE    NECK,  167 

upon  the  anterior  part  of  the  common  carotid.  Sometimes  it 
abandons  this  vessel,  approximating  nearer  the  larynx  or  trachea, 
but  more  frequently  passes  outwards  upon  the  jugular  vein.  In 
either  case  we  should  bear  it  well  in  mind  when  we  wish  to  tie 
the  common  carotid  ;  for  it  is  much  better  to  make  a  complete 
section  of  this  nerve  than  to  comprise  it  in  the  ligature.  It  is  in 
the  vicinity  of  the  omo-hyoideus  muscle  that  it  unites  with  the 
internal  descending  branch  of  the  cervical  plexus.  The  filaments 
originating  from  this  union  form,  in  certain  subjects,  behind  or 
beneath  this  muscle,  a  sort  of  plexus,  called  by  some  the  super- 
ficial cervical  plexus. 

Previous  to  these  filaments  being  distributed  to  the  muscles, 
they  cover  the  primitive  carotid  artery,  and  cause  more  or  less 
perplexity  when  we  apply  a  ligature  around  this  vessel  in  the 
omo-tracheal  triangle. 

(  c )  In  the  third  place  we  find  the  par  vagum  (pueumo-gastrique), 
the  largest  and  most  remarkable  of  all  the  nerves  of  the  neck. 
This  nerve  is  situated  before  the  base  of  the  cervical  transverse 
processes  and  the  soft  parts  which  immediately  cover  them,  and 
is  itself  covered  by  the  carotid  and  the  internal  jugular  vein :  it 
is  then  between  and  behind  these  two  vessels  that  we  constantly 
find  the  par  vagum ;  before,  on  the  outer,  and  sometimes  on  the 
inner  side  of  the  great  sympathetic  nerve,  to  which  it  is  always 
closely  approximated.  In  this  place,  the  pneumo-gastric  nerve 
cannot  be  confounded  with  any  other  organ.  The  lamellated 
cellular  tissue  which  envelopes  it  is  very  dense  and  very  com- 
pact ;  and  as  it  is  this  same  cellular  tissue  which  forms  a  sheath 
for  the  artery,  it  follows  that  we  should  be  particular,  when  tying 
the  latter,  to  exclude  the  nerve  from  the  ligature.  In  order  that 
we  may  accomplish  this  end  more  surely,  and  at  the  same  time 
disturb  the  parts  as  little  as  possible,  we  should  introduce  the 
needle  close  along  the  outer  side  of  the  artery,  leaving  the  par 
vagum  external  to  it. 

This  step  is  also  rendered  much  more  easy  by  making  a  cau- 
tious incision  through  the  arterial  sheath,  previously  pinching  up 
this  sheath,  and  making  a  small  horizontal  cut,  sufficiently  large 
to  admit  the  introduction  of  a  director,  upon  which  the  opening 
may  be  dilated.  In  this  manner  the  artery  is  completely  isolated, 
all  the  nerves  remain  untouched ;  no  tissue  is  lacerated,  in  short  all 


168 


OF  THE    NECK. 


the  parts  are  left  in  the  state  best  adapted  for  their  prompt  reunion. 

The  par  vagum  gives  oft'  two  principal  branches  in  the  sub- 
hyoidean  region,  which  are  the  two  laryngeal  nerves, 

(  d  )  The  superior  laryngeal  nerve  separates  from  the  trunk 
opposite  the  os  hyoides,  and  is  at  first  situated  behind  the  carotid, 
near  its  bifurcation ;  it  then  glides  along  its  inner  side,  in  order  to 
arrive,  on  the  one  hand,  at  the  posterior  part  of  the  thyroid  gland, 
and  on  the  other,  upon  the  thyro-hyoid  membrane ;  sometimes  it 
is  situated  higher  up  than  the  superior  thyroid  artery,  at  others, 
lower  down,  but  always  deeper.  Nevertheless,  it  follows  nearly 
the  same  direction  as  this  artery ;  a  circumstance  which  must  be 
recollected  when  we  wish  to  tie  this  vessel ;  for  the  section  of  this 
nerve  would  almost  certainly  be  attended  with  dumbness. 

( e  )  The  inferior  branch,  or  recurrent  nerve,  is  longer  on  the 
left  side  than  on  the  right,  because,  in  the  first  direction,  it  passes 
under  the  arch  of  the  aorta,  whilst,  in  the  second,  it  turns  round 
the  subclavian  and  ascends  to  the  larynx  along  the  cesophago-tra- 
cheal  gutter,  or,  in  other  words,  between  the  carotid  artery  which 
is  external,  the  oesophagus  and  trachea,  which  are  internal.  This 
nerve  is  at  first  nearest  the  artery,  but  afterwards  approximates 
the  respiratory  and  alimentary  tubes,  to  which  it  distributes  a 
great  number  of  filaments.  Hence  it  follows  that  the  inferior 
laryngeal  nerve  may  be  wounded  in  cesoplwgotomy ;  in  extirpa- 
ting the  thyroid  gland ;  in  tying  the  inferior  thyroid  arteries,  or 
the  common  carotid  when  performed  in  the  omo-tracheal  trian- 
gle, or  the  subclavian  on  the  inner  side  of  the  sterno-mastoideus 
muscle. 

(/ )  We  must  also  notice  the  cardiac  filaments  given  off  by  the 
eighth  pair.  They  are  more  numerous  on  the  left  side  than  on  the 
right,  and  remain  a  long  time  behind  the  trunk  of  the  carotid.  Of 
themselves  they  posses  but  little  consistency,  but  their  tenacity  is 
very  much  augmented  by  the  cellular  tissue  which  envelopes  them. 
They  are  particularly  adherent  to  the  arterial  sheath,  especially 
in  the  upper  half  of  the  region,  which  affords  an  additional  mo- 
tive for  opening  this  sheath  when  we  wish  to  tie  the  carotid  ;  in- 
deed, without  this  precaution,  it  might  frequently  happen  that  one 
of  the  cardiac  nerves  of  the  par-vagum  would  be  included  in  the 
ligature,  which  would  not  fail  to  occasion  more  or  less  disturb- 
ance in  the  action  of  the  heart. 


OP   THE    NECK.  169 

(g )  The  great  sympathetic  nerve  (le  nerf  de  la  vie  interieure)  is 
;dso  concealed  by  the  carotid,  lying  deeper  than,  and  on  the  inner 
side  of,  the  par-vagum.  A  part  of  its  superior  ganglion,  the  whole 
of  its  middle  ganglion,  when  it  exists,  the  two  cardiac  nerves, 
and  numerous  accessory  filaments  are  found  in  this  region.  En- 
veloped in  the  lamellated  tissue  of  the  deep  parts  of  the  neck, 
having  nearly  the  same  relations  with  the  important  vessels  of 
this  part,  the  great  sympathetic  nerve  is  susceptible  of  the  same 
surgical  applications  as  the  nervus  vagus,  when  we  perform  ope- 
rations upon  this  region. 

ix.   The  Larynx  and  Trachea- Arteria. 

Situated  upon  the  median  line,  the  laryngo-tracheal  canal  pre- 
sents relations  which  are  common  to  all  the  parts  entering  into 
its  composition,  and  others  which  are  peculiar  to  each  of  these 
parts.  It  is  covered  throughout  its  whole  extent ;  anteriorly,  by 
the  double  sheet  of  the  cervical  aponeurosis,  the  subcutaneous  lay- 
er and  skin ;  more  externally,  by  the  sterno-hyoidei  muscles,  the 
aponeurosis,  the  platysma  and  the  two  laminae  which  envelope  it, 
lastly  by  the  skin.  The  carotid  arteries,  pneumo-gastric  nerves, 
great  sympathetic,  and  the  jugular  vein,  run  deep  along  its  sides 
throughout  its  whole  extent. 

The  different  portions  of  this  canal  also  have  special  relations, 
which  must  be  examined  separately. 

(  a  )  In  the  first  place  we  find  the  thyro-hyoid  membrane,  of 
the  nature  of  the  ligamenta  flava  (ligamensjaunes),  the  posterior 
surface  of  which,  separated  from  the  epiglottis  by  a  triangular 
space  which  is  filled  with  adipose  cells  and  which  lodges  the  epi- 
glottic  gland  (periglottis),  is  only  removed  from  the  pharynx  by 
the  mucous  membrane. 

Anteriorly,  this  membrane  is  covered  by  an  arterial  branch 
and  some  small  twigs  of  the  superior  thyroid ;  by  the  superior 
laryngeal  nerve,  which  penetrates  through  it  into  the  larynx,  into 
which  some  filaments  from  the  ninth  pair  also  pass ;  by  a  cellu- 
lar layer  in  which  the  vessels  and  nerves  just  mentioned  are  im- 
bedded ;  by  the  omo-hyoideus,  sterno-hyoideus,  and  thyro-hyoi- 
deus  muscles ;  finally  by  the  aponeurosis,  platysma  and  the  skin. 

The  length  of  the  thyro-hyoid  membrane  is  about  sixteen  lines. 


170  OF    THE    NECK. 

and  it  is  thicker  in  the  middle  than  upon  the  sides.  From  it? 
disposition,  instruments  or  weapons  which  divide  it  transversely, 
or  in  any  other  direction,  naturally  tend  to  pass  into  the  pharynx, 
and,  consequently,  may  not  strike  the  glottis :  for  which  reason 
these  wounds  do  not  ordinarily  produce  mutismus,  since  the  voice 
is  incontestibly  formed  in  the  larynx.  Nevertheless,  these  wounds 
may  occasion  unpleasant  consequences,  from  their  frequently 
dividing  the  laryngeal  nerve  and  the  thyro-hyoid  artery.  As  this 
membrane  is  more  depressed  than  the  os  hyoides  and  thyroid 
cartilage,  there  is  consequently  a  species  of  groove  formed  be- 
tween these  two  organs,  and  it  is  in  this  groove  that  instruments 
are  most  commonly  placed  in  attempts  at  suicide ;  and  it  is  for 
this  reason  that  individuals  desirous  of  committing  this  act,  do  not 
always  succeed  in  accomplishing  it.  It  is  likewise  in  this  place 
that  the  knot  of  the  hangman's  cord  generally  stops. 

(  b  )  The  Larynx,  properly  so  called,  presents  for  our  conside- 
ration, in  the  first  place,  the  thyroid  cartilage  ;  next  the  cricoid, 
and  lastly  the  crico-thyroid  membrane. 

The  first  is  harder  and  more  disposed  to  ossify  than  the  second ; 
its  superior  margin  is  notched  out  and  forms  a  very  considerable 
prominence,  especially  in  man  ;  indeed  the  difference  in  the  de- 
gree of  this  prominence  is  so  great  in  the  two  sexes,  that  it  would 
merely  be  necessary  to  feel  this  part  in  the  adult  in  order  to  dis- 
tinguish them.  This  cartilage  is  about  an  inch  in  length  ;  its  ex- 
ternal surface  forms  two  planes  which  are  inclined  backwards, 
upon  which  the  thyro-hyoid  and  sterno-thyroid  muscles  rest ;  its 
internal  surface  presents  two  other  planes  which  include  the  es- 
sential parts  of  the  larynx,  that  is  to  say,  the  parts  which  consti- 
tute the  glottis ;  and  it  is  in  the  retiring  angle  formed  by  their  con- 
junction, two  lines  below  the  superior  median  notch,  that  we  find 
the  anterior  extremity  of  the  cordce  vocales,  then  a  little  lower,  the 
thyro-arytenoidei  muscles  ;  so  that  in  performing  laryngotomy,  ac- 
cording to  Desault's  method,  the  cartilage  should  be  divided  ex- 
actly upon  the  median  line,  otherwise  we  will  be  liable  to  wound 
the  ligaments  of  the  glottis. 

The  second,  or  cricoid  cartilage,  increases  in  width  as  it  pro- 
ceeds backwards,  and  is  surmounted  posteriorly  by  the  arytenoid 
cartilages,  which  are  articulated  with  it  in  such  a  manner  that  they 
may  be  flexed  anteriorly  and  laterally,  according  to  our  opinion 


OF   THE   NECK.  171 

and  that  of  most  physiologists ;  or  laterally  only,  as  M.  Magendie 
supposes.  Posteriorly,  this  cartilage  is  covered  by  the  crico-ary- 
tenoidei  postici  and  laterales  muscles  ;  afterwards  it  corresponds 
to  the  origin  of  the  oesophagus,  or  to  the  termination  of  the  pha- 
rynx ;  laterally,  we  find  the  crico-thyroidei  muscles  ;  anteriorly, 
there  are  no  particular  organs,  excepting  occasionally  some  vascu- 
lar ramusculi ;  it  is  seldom  that  the  thyroid  gland  reaches  so  high 
up.  It  is  on  a  level  with  it  that  the  trunk  of  the  recurrent  nerve 
is  lost  among  the  tissues,  after  the  same  manner  that  the  superior 
laryngeal  nerve  is  expanded  above  the  thyroid  cartilage  ;  and  the 
last  twigs  of  these  nerves  are  distributed  to  the  proper  muscles  of 
the  larynx.  But  authors  are  not  agreed  respecting  the  precise 
spot  where  they  terminate.  M.  Magendie  thinks  that  the  superior 
laryngeal  is  distributed  merely  to  the  arytenoid  and  crico-thyroid 
muscles,  whilst  the  inferior  distributes  its  filaments  to  the  crico- 
arythenoid  and  thyro-arytenoid  muscles  ;  so  that  there  would  be 
a  distinct  nerve  for  the  dilator  muscles,  and  another  for  the  con- 
strictor muscles  of  the  glottis  ;  but  notwithstanding  the  authority 
of  this  savant,  we  cannot  subscribe  to  his  opinion,  because  we 
have  frequently  traced  a  filament  of  the  recurrent  nerve  even 
into  the  arythenoid  muscle,  etc. 

The  transverse  diameter  of  the  membrana  crico-thyroideais  four 
or  five  lines,  its  perpendicular  height  from  three  to  four  ;  it  is  of 
the  same  nature  as,  but  much  stronger  than  the  thyro-hyoid  mem- 
brane. Its  use  appears  to  be  merely  to  fill  up  the  space  which 
separates  the  cricoid  and  thyroid  cartilages :  it  becomes  folded 
when  these  cartilages  approximate  or  overlap  each  other,  and  for 
this  reason  the  chin  should  be  elevated  when  we  puncture  this 
membrane.  No  organ  of  importance  covers  it  anteriorly,  except- 
ing the  crico-thyroid  artery  ;  and  in  order  to  lay  bare  this  mem- 
brane, we  will  have  to  divide  the  skin,  fascia  superficialis,  platys- 
ma  and  the  layer  which  supports  it,  the  aponeurosis  and  the  sev- 
eral cellular  sheets  which  are  collected  upon  the  median  line  after 
having  enveloped  the  muscles,  which  are  also  easily  separated. 
The  artery,  however,  deserves  the  greatest  attention,  as  it  almost 
always  forms  a  complete  loop  which  crosses  this  membrane  trans- 
versely. If  this  loop  was  of  considerable  volume,  which  is  fre- 
quently the  case,  its  division  might  occasion  a  troublesome  hoe- 
morrhage  :  on  the  one  hand,  because  it  would  be  difficult  to  stop 


17*2  OF    THE    NECK. 

the  blood  by  compression ;  and  on  the  other,  because  this  fluid 
might  make  its  way  into  the  larynx,  through  the  opening  which 
has  been  made,  and  produce  suffocation :  therefore  the  two  ex- 
tremities of  the  arterial  arch  should  be  tied  as  soon  as  divided. 
In  order,  however,  that  we  may  avoid  a  similar  accident,  in  per- 
forming the  operation  recommended  by  Vicq.  d'Azyr,  we  may 
proceed  in  different  ways.  For  example,  do  we  wish  to  open 
the  crico-thyroid  membrane  simply  for  the  purpose  of  giving  ad- 
mission to  air,  we  should  incise  the  tissues  parallel  to  the  direc- 
tion of  the  artery,  which  we  push  up  or  draw  down  with  the  nail  ; 
do  we,  on  the  contrary,  operate  in  order  to  extract  a  foreign  body, 
one  of  two  cases  will  be  present ;  either  this  body  will  be  above 
the  cricoid  cartilage,  or  it  will  be  below  it.  In  the  first  case  we 
would  be  obliged  to  follow  the  advice  of  Desault,  which  is  to  di- 
vide the  thyroid  cartilage  from  below  upwards ;  then  before  we 
perforate  the  membrane,  we  should  ascertain  the  size  and  exact 
situation  of  the  artery.  If  the  finger  does  not  discover  it,  or  its 
pulsations  are  not  felt,  it  is  certain  that  this  vessel  is  small,  and 
that  its  section  will  not  be  attended  with  danger.  If,  on  the  other 
hand,  its  pulsations  are  very  perceptible,  we  may  be  sure  that  its 
volume  is  considerable,  and  we  should  then  draw  it  down  as  much 
as  possible,  in  order  to  commence  the  incision  above  it,  or  if  we 
cannot  dispense  with  cutting  it,  it  would  be  better  to  tie  it  before- 
hand. 

In  the  second  case,  it  will  be  necessary  to  divide  the  cricoid  car- 
tilage from  above  downwards,  as  recommended  by  Boyer,  and 
then  the  artery  will  require  the  same  precautions  as  in  the  pre- 
ceding, except,  however,  that  it  should  be  drawn  upwards.  We 
must  also  recollect  that  the  air-tube  is  only  seven  or  eight  lines  in 
diameter  opposite  to  the  part  under  consideration,  so  -that  we 
should  hold  the  bistoury  in  such  a  manner  that  it  will  not  penetrate 
its  posterior  wall.  For  the  same  reason  also  we  should,  when 
we  divide  either  of  the  cartilages,  use  a  probe-pointed  bistoury, 
and  the  canula  which  we  introduce  should  be  so  short  that  its  ex- 
tremity will  remain  free  in  the  laryngo-tracheal  canal. 

( c  )  The  Trachea.  Its  two  superior  third  portions  exist  in  tin* 
sub-hyoidean  region ;  its  membranous,  or  posterior  fourth  por- 
tion, lies  upon  the  oesophagus,  to  which  it  is  united  by  means  of  a 
lax  cellular  tissue,  and  from  this  disposition  we  may  account  for 


OF    THE    NECK. 

the  passage  of  foreign  bodies,  which  have  lodged  in  the  resopha- 
gus,  into  the  trachea,  and  vice  versa ;  anteriorly  and  laterally  it  is 
immediately  enveloped  by  the  thyroid  gland. 

Although  the  functions  of  the  thyroid  gland  have  not  been 
correctly  ascertained  by  physiologists,  it  nevertheless  performs  an 
important  part  in  surgery ;  either  on  account  of  the  diseases  to 
which  it  is  exposed,  or  its  complicated  relations. 

This  gland  is  enveloped  in  a  species  of  fibro-cellular  sac,  which 
is  sometimes  so  dense  that  it  is  very  difficult  to  distinguish  the  fluc- 
tuation of  pus  or  any  other  fluids  which  may  be  collected  within 
it,  and  it  is  this  envelope  also  which  permits  the  thyroid  to  become 
considerably  enlarged  without  contracting  intimate  adhesions  with 
the  surrounding  organs. 

The  two  lobes  which  constitute  it  are  sometimes  almost  com- 
pletely separated,  or  at  least  united  by  a  single  band,  which  is 
sometimes  placed  at  its  inferior  part,  leaving  the  larynx  and  three 
or  four  rings  of  the  trachea  completely  free  in  the  sinus  which 
results  from  it ;  a  disposition  which  admits  of  the  performance  of 
laryngo-tracheotomy  without  danger  ;  at  other  times,  on  the  con- 
trary, the  vinculum  is  much  higher  up,  sometimes  even  on  a  level 
with  the  cricoid  cartilage,  when  the  preceding  operation  will  be 
attended  with  some  hazard.  There  are  also  other  cases  in  which 
these  two  lobes  are  blended  together  along  almost  the  whole  of 
their  internal  border ;  whereby  the  air-tube  is  entirely  concealed 
by  the  gland,  from  the  larynx  to  the  fifth,  sixth,  and  sometimes 
even  the  seventh  cartilaginous  ring. 

Anteriorly,  this  gland  is  convex  and  covered  by  the  anterior 
sheet  of  its  capsule,  by  the  sterno-thyroid  and  sterno-hyoid  mus- 
cles and  the  common  integuments;  the  omo-hyoideus  passes 
more  externally  and  superiorly.  Posteriorly  it  is  excavated  in 
the  form  of  a  gutter,  in  order  to  receive  the  commencement 
of  the  trachea,  from  which  it  is  separated  only  by  a  dense 
cellular  layer  and  its  tunica  propria.  Laterally  it  rests  upon 
the  inferior  laryngeal  nerves,  slightly  upon  the  oesophagus  on 
the  left,  upon  the  primitive  carotid  artery  and  upon  the  origin 
of  the  principal  divisions  of  the  arteries  which  bear  its  name. 

From  these  relations  it  follows  that  tumours  of  the  thyroid 
gland,  bound  down  by  the  cervical  aponeurosis  and  the  muscles, 
may  enlarge  most  posteriorly,  and  by  compressing  the  trachea 


174  OF    THE    NECK. 

and  other  organs  lying  in  this  direction,  give  rise  to  serious  con- 
sequences. It  is  with  the  view  of  preventing  these  consequences 
as  well  as  removing  a  disease  in  itself  fatal,  that  surgeons  have 
so  frequently  manifested  a  desire  to  extirpate  the  thyroid  body. 
We  may  now  readily  appreciate  the  difficulties  of  such  an  opera- 
tion ;  in  fact  the  division  of  the  muscles,  almost  always  indispen- 
sable, must,  even  admitting  its  complete  success^  in  a  great  mea- 
sure prevent  the  depression  of  the  os  hyoides,  after  the  cure. 
The  inevitable  division  of  four  or  five  thyroid  arteries  demands 
a  multiplicity  of  ligatures,  and  may  give  rise  to  an  exhausting 
haemorrhage.  The  innumerable  veins  which  are  contained  in  this 
organ,  must  likewise  pour  fourth  an  abundance  of  blood,  because, 
in  these  agonizing  moments,  inspiration  is  but  indifferently  per- 
formed. We  have  also  to  apprehend  the  admission  of  air  into 
the  open  mouths  of  these  veins,  which,  in  the  opinion  of  M.  Lar- 
rey,  from  Magendie's  experiments,  and  some  cases  derived  from 
man,  among  others  those  which  have  come  under  the  observation 
of  Dupuytren,  etc.,  may  cause  the  instantaneous  death  of  the 
patient.  Neither  must  we  forget  that,  in  the  pathological  state  of 
the  thyroid  requiring  its  extirpation,  all  these  vessels  have  under- 
gone considerable  dilatation.  Finally,  the  thyroid  gland  is  some- 
times so  greatly  enlarged  externally,  and  so  intimately  united  to 
the  parts  situated  behind  it,  that  it  is  sometimes  diffcult  to  avoid 
the  trachea,  the  carotid  and  even  the  internal  jugular  vein. 

Notwithstanding  all  these  unfavourable  circumstances,  the  ope- 
ration under  consideration  has  already  been  performed  a  great 
number  of  times,  and  M.  Hedenus  relates  six  cases  of  goitre  in 
which  it  has  been  attended  with  complete  success.* 

The  means  by  which  most  of  these  dangers  and  difficulties  may 
be  avoided  is  by  previously  tying  the  four  thyroid  arteries.  This 
preliminary  step  of  the  operation  is  generally  of  easy  perform- 
ance upon  the  dead  subject.  Walther  de  Bonn  has  successfully 
performed  it  upon  the  living  for  an  aneurismatic  goitre.  Perhaps 
it  would  be  well  also  to  tie  the  large  sub-thyroid  venous  trunks, 
in  order  to  prevent  the  admission  of  air  into  them  ;  and,  finally, 
we  might  preserve  in  part  the  action  of  the  muscles  upon  the 

*  Commenlarius  de  glandulx  thyro'idece  exlirpatione.  Hedenus  filius.  Leipsick. 
1822,  4to. 


OF   THE   NECK.  175 

larynx,  by  previously  cutting  them  across,  and  reflecting  them 
towards  their  points  of  attachment,  in  order  that  their  extremities 
may  be  approximated  after  the  operation. 

Below  the  thyroid  gland,  the  trachea-arteria  corresponds  to  the 
supra-sternal  fossette  of  the  sub-hyoidean  region.  Its  immediate 
covering  is  a  lamellated  and  filamentous  cellular  tissue,  in  which 
there  are  a  great  quantity  of  adipose  vesicles,  and  sometimes  one 
or  more  lymphatic  glands,  the  tumefaction  of  which  might  occa- 
sion great  disturbance  in  the  exercise  of  the  respiratory  and  di- 
gestive functions.  These  diseased  glands  may  be  mistaken  for 
aneurism  of  the  commencement  of  the  carotids  or  subclavians,  or 
for  a  pathological  developement  of  the  thymus,  which,  in  children, 
naturally  ascends  a  little  into  the  supra-sternal  space.*  On  the 
other  hand,  this  cellular  tissue  is  sometimes  the  seat  of  acute  or 
chronic  inflammations  which  terminate  by  suppuration,  the  ab- 
scesses resulting  from  which  are  generally  detected  with  difficul- 
ty, on  account  of  the  aponeurosis  behind  which  they  are  situated. 
It  is  very  essential,  however,  to  open  them  early ;  for  the  fluid 
will  penetrate  into  the  chest  with  the  greatest  facility. 

In  the  next  place  we  find,  in  proceeding  from  the  deep-seated 
parts  towards  the  skin,  the  inferior  thyroid  veins ;  the  artery  of 
the  same  name,  when  it  exists ;  the  aponeurosis,  which  is  here 
very  thick,  and  lastly  the  subcutaneous  cellulo-adipose  layer. 
The  latter  lamina  is  usually  very  thin,  and  the  purulent,  or  other 
fluids,  which  collect  in  it,  soon  render  the  skin  prominent.  The 
aponeurosis  here  consists  of  two  very  distinct  sheets,  one  of 
which  is  fixed  to  the  anterior,  the  other  to  the  posterior  part  of 
the  sternum ;  so  that  abscesses  or  tumours  which  are  developed 
between  them,  do  not  communicate  so  directly  with  the  cavity 
of  the  thorax  as  they  do  when  they  form  in  the  cellular  tissue 
which  immediately  covers  the  trachea.  The  veins  are  naturally 
very  large  ;  but  they  are  considerably  larger  in  goitre  and  other 
affections  of  the  thyroid  gland :  these  are  the  veins  which  render 
bronchotomy,  or  rather  tracheotomy  so  dangerous  that  several  in- 
telligent persons  have  thought  proper  to  proscribe  this  operation. 
The  principal  cause  of  apprehension  is  that  the  blood,  which  ob- 
scures the  view  of  the  operator,  will  make  its  way  into  the  air 

*  Burns. 


i?6 


OF    THE 


tube  and  produce  suffocation.  A  case  related  by  Virgili  strength- 
ens this  opinion.  Besides,  we  find  it  more  convenient  and  less 
dangerous  to  divide  the  crico-thyroid  membrane  only,  when  our 
object  is  to  re-establish  respiration,  and  at  the  same  time  to  di- 
vide one  or  the  other  of  the  cartilages  when  it  is  required  to  ex- 
tract a  foreign  body  ;  nevertheless  the  trachea  has  been  opened  a 
great  number  of  times  between  the  thyroid  gland  and  sternum,  in 
the  last  stage  of  croup,  without  any  serious  consequences  apparent- 
ly resulting  from  it.  The  greater  part  of  the  subjects  died,  it  is 
true;  but  it  is  too  evident  that  the  fatal  termination  was  to  be  at- 
tributed to  the  disease,  not  to  the  operation.  Indeed,  it  would 
seem  that  this  therapeutic  resource  has  been  too  frequently  re- 
jected in  this  dreadful  angina.  It  is  at  least  a  fact  that,  by  this 
means,  M.  Bretonneau  succeeded  in  saving  the  life  of  the  daugh- 
ter of  Count  Puysegur.  Three  of  the  children  of  this  learned 
philanthropist  had  been  cut  off  by  croup  ;  the  fourth  appeared 
without  resource,  and  upon  the  point  of  undergoing  the  fate  of 
her  brothers.  M.  Bretonneau,  encouraged  by  the  unhappy  father 
of  the  little  patient,  decided  upon  dividing  the  trachea  ;  portions 
of  the  accidental  membrane  in  the  form  of  shreds,  and  sometimes 
resembling  cylinders  moulded  upon  the  bronchi,  were  expelled 
or  extracted  during  several  days,  and  on  the  fifteenth  day  after 
the  operation  the  patient  was  completely  cured. 

In  order  to  avoid  the  accident  which  caused  the  death  of  Vi- 
gili's  patient,  we  should  cut  three  rings  of  the  trachea  at  least  ;  by 
this  means  the  blood  which  flows  into  the  trachea  during  inspira- 
tion is  expelled  by  expiration  ;  and  there  is  no  danger  from  a 
large  opening  made  into  this  canal. 

When  the  thyroid  artery  of  Neubauer  exists,  it  is  situated  be- 
hind the  veins,  and  usually  a  little  to  the  right.  It  may  likewise 
be  distinguished  by  its  pulsations,  the  thickness  of  its  coats  .nd 
the  distribution  of  its  branches. 

More  externally,  the  relations  of  the  trachea  are  not  exactly 
the  same  on  the  left  side  as  on  the  right  ;  that  is  to  say,  the  apon- 
eurotic  sheets  and  sterno-hyoid  and  sterno-thyroid  muscles,  etc., 
cover  it  equally  on  both  sides  ;  but  the  primitive  carotid  is  closer 
to  it,  more  anterior  and  more  superficial  on  the  right  than  on  the 
left  ;  a  disposition  which  it  is  important  to  note,  especially  on  ac- 
count of  the  mobility  of  the  air-tube  ;  for  if  the  latter  should  glide 


OF   THE    NECK.  1?7 

only  a  few  lines  to  the  right,  when  we  are  performing  tracheotomy 
in  the  inferior  part  of  the  neck,  the  instrument  is  in  danger  of 
falling  upon  the  carotid  artery ;  a  circumstance  which  actually 
happened  to  a  student  of  medicine,  who  was  desirous  of  resusci- 
tating one  of  his  friends,  whilst  in  a  state  of  asphyxia. 

The  great  mobility  of  the  laryngo-tracheal  canal  is  a  circum- 
stance against  which  we  cannot  be  too  much  upon  our  guard, 
and  it  is  for  the  purpose  of  restraining  this  that  the  instrument  of 
Bauchot  was  invented.  It  is  this  mobility  which  principally  pre- 
vents our  penetrating  this  tube  by  a  simple  puncture,  whether 
we  make  use  of  the  trois-quarts  recommended  by  Junkers,  Deck- 
ers, etc.,  or  the  sharp-pointed  bistoury  as  advised  by  Dionis.  The 
trachea  will  always  tend  to  slide  under  these  instruments ;  and, 
on  the  other  hand,  if  their  point  should  succeed  in  perforating  it, 
the  force  made  use  of  to  overcome  the  resistance  which  its  elas- 
ticity occasions,  will  frequently  carry  the  instrument  so  far  as  to 
wound  other  organs. 

In  addition  to  the  mobility  and  elasticity  of  this  canal,  there  is 
still  another  reason  why  we  should  not  employ  puncturing  instru- 
ments in  tracheotomy.  In  fact,  a  single  puncture  being  only 
serviceable  in  admitting  air  into  the  lungs,  it  will  always  be  more 
easy  and  safe  to  make  an  opening  between  the  two  cartilages  of 
the  larynx  than  through  the  trachea.  But  in  croup,  as  well  as 
for  the  extraction  of  foreign  bodies,  it  is  necessary  to  incise  sev- 
eral fibro-cartilaginous  rings  vertically;  for  punctures,  in  such 
cases,  would  always  be  insufficient ;  and  we  may  remark  finally, 
that  by  dividing  the  tissues  parallel  to  the  trachea,  it  is  much  more 
easy  to  separate  the  vessels  which  cover  it. 

It  remains  for  us  to  mention,  before  concluding  our  observa- 
tions on  this  important  canal,  that  the  escape  of  the  air  through 
an  aperture  below  the  thyroid  cartilage  invariably  destroys  the 
voice ;  therefore  surgeons  should  always  make  it  a  rule  to  bring 
the  divided  edges  of  the  wounds  of  these  parts  in  as  exact  coap- 
tation  as  possible.  Sounds  being  formed  in  the  glottis,  it  is  evi- 
dent that,  if  the  air,  which  is  the  sonorous  body,  escapes  below  it, 
the  voice  will  not  be  formed.  Numerous  experiments  made 
upon  dogs  by  Bichat,  and  others,  as  well  as  observations  derived 
from  man  by  MM.  J.  Cloquet  and  Magendie,  have  demonstrated 
this  point  of  physiology  to  a  mathematical  certainty. 

23 


178  OF    THE    NECJK. 


x.  The  (Esophagus. 

The  oesophagus  commences  opposite  to  the  fourth  cervical 
vertebra,  and  appears  to  be  only  the  continuation  of  the  pharynx ; 
the  inferior  part,  is  consequently,  comprised  in  the  sub-hyoidean 
region. 

The  oesophagus  is  at  first  situated  upon  the  median  line  behind 
the  cricoid  cartilage,  and  afterwards  inclines  slightly  to  the  left, 
so  as  to  pass  a  few  lines  beyond  the  trachea  in  this  direction. 
It  rests  upon  the  bodies  of  the  vertebrae,  and  is  connected  to  the 
fibrous  tissues  which  unites  these  bones  only  by  very  extensible 
cellular  lamina?.  We  have  already  stated  that  its  anterior  por- 
tion was  pretty  intimately  attached  to  the  posterior  gutter  of  the 
trachea.  On  the  right,  it  is  in  part  concealed  by  the  latter  organ, 
and  close  along  this  side  runs  the  recurrent  nerve,  then  the  car- 
rotid  artery,  etc.  On  the  left,  it  is  more  immediately  covered 
by  the  thyroid  gland ;  it  is  crossed  by  the  inferior  thyroid  artery, 
and  the  recurrent  nerve  is  more  upon  its  anterior  part  than  on 
the  right  side  ;  which  renders  the  section  of  this  cord  more  easy : 
finally,  the  carotid  is  a  little  nearer  to  it,  because  on  the  right  the 
esophagus  is  entirely  covered  by  the  trachea. 

It  is  owing  to  these  anatomical  relations  that  it  is  laid  down 
as  a  rule  always  to  perform  cesophagotomy  on  the  left  side,  and  as- 
much  as  possible  between  the  thyroid  gland  and  sternum.  In 
order  to  reach  the  oesophagus  at  this  point,  we  cut  down  as  if  we 
were  about  to  tie  the  carotid ;  we  then  push  this  artery  out- 
wards, the  sterno-thyroideus  muscle  forwards  and  towards  the 
median  line ;  a  thick  fibro-cellular  lamina  presents  itself,  which 
is  next  to  be  divided,  when  the  canal  of  deglutition  is  exposed  to 
view.  All  that  is  then  necessary  to  avoid  is  the  recurrent  nerve 
and  trachea. 

However,  notwithstanding  surgeons  have  kept  silence  in  this 
respect,  foreign  bodies  can  seldom  descend  so  low  and  then  stop, 
if  it  is  their  magnitude  alone  which  opposes  their  passage  to  the 
stomach.  In  fact,  when  they  have  succeeded  in  passing  the  ori- 
gin of  the  oesophagus,  and  have  got  beyond  the  cricoid  cartilage 
we  do  not  see  what  can  impede  their  further  progress.  There- 
fore, it  is  on  a  level  with  the  inferior  part  of  the  larynx  that  we 


OF   THE   NECK.  179 

will  be  most  frequently  obliged  to  perform  cesophagotomy.  The 
operation  will  then  be  much  more  difficult  and  dangerous,  since 
we  will  have  to  avoid  the  thyroid  gland  and  its  arteries,  and  will 
also  have  to  cut  deeper  for  the  organ,  which  has  not  as  yet  devi- 
ated to  one  side  or  the  other.  In  all  these  cases  the  instrument 
of  M .  Vacca  Berlinghieri,  or  that  of  Prof.  Dupuytren  will  over- 
come many  difficulties. 

xi.  The  Skeleton. 

There  is  no  skeleton  properly  appertaining  to  the  sub-hyoidean 
region :  it  rests  upon  the  bodies  of  the  last  four  cervical  verte- 
brae. These  bones  form  a  convexity  at  this  part,  which  seems  to 
serve  as  a  point  of  support  to  certain  very  heavy  metallic  rods, 
introduced  by  jugglers  into  the  oesophagus  and  balanced  in  the 
air.  We  will  have  occasion,  however,  to  speak  of  the  spinal 
column  in  another  place. 

Sect.  3.  The  Supra- Clavicular  Region.     (See  plate  4.) 

The  supra-clavicular  region  is  bounded,  anteriorly,  by  the  sub- 
hyoidean,  submaxillary,  and  parotideal  regions ;  that  is  to  say,  by 
a  line  drawn  from  the  sterno-clavicular  articulation,  along  the 
anterior  margin  of  the  sterno-mastoid  muscle  to  the  anterior  part 
of  the  mastoid  process ;  posteriorly,  by  another  line  extended 
from  the  acromio-clavicular  articulation,  along  the  anterior  bor- 
der of  the  trapezius,  to  the  posterior  part  of  the  mastoid  process ; 
and  inferiorly,  by  the  clavicle  and  first  rib.  Consequently,  it 
forms  a  regular  triangle  with  its  base  below. 

Upon  its  anterior  limit  we  observe  an  elongated  eminence, 
which  is  very  evident  when  the  head  is  inclined  towards  the 
shoulder,  and  the  face  to  one  side,  and  which  is  formed  by  the 
sterno-mastoid  muscle.  The  trapezius  forms  another  relief  pos- 
teriorly, which  is  blended  at  the  summit  with  the  preceding  emi- 
nence. In  the  interval  of  these  two  species  of  columns  there  is 
an  excavation,  which  is  deeper  in  the  adult  than  the  child,  in  man 
than  in  woman,  in  thin  than  in  fat  subjects,  and  which  is  increased 
or  diminished  according  to  the  elevation  or  depression  of  the 
shoulder.  This  is  the  supra-clavicular  excavation,  and  is  the  most 


180 


OP   THE    NECK, 


important  part  of  the  region,  whether  we  consider  it  in  relation 
to  the  numerous  organs  it  includes,  the  diseases  which  are  de- 
veloped in  it,  or  the  operations  which  may  be  performed  upon  it, 

CONSTITUENT   PARTS. 

i.  The  Skin. 

This  membrane  is  very  strong,  very  thick,  and  but  slightly 
extensible  superiorly,  where  it  is  firmly  adherent  to  the  subjacent 
tissues;  but  as  it  descends  it  gradually  becemes  thinner  and 
more  moveable  upon  the  muscles  ;  so  that  in  the  supra-clavicular 
fossette,  it  assumes  all  the  characters  which  distinguish  the  skin  of 
the  sub-hyoidean  region.  In  some  persons  it  is  dark  coloured 
and  covered  with  hairs,  in  the  superior  fourth  part  of  the  region ; 
throughout  the  rest  of  its  extent  it  is  smooth,  and  contains  a  few 
small  sebaceous  follicles. 

ii.  The  Subcutaneous  Layer. 

This  layer,  like  that  of  the  preceding  region,  is  composed  of  a 
cellulo-adipose  lamina,  immediately  attached  to  the  skin  ;  of  the 
platysma,  which  does  not  extend  quite  to  the  margin  of  the  tra- 
pezius,  and  of  another  supra-aponeurotic  cellular  lamina,  which 
resembles  the  fascia  superficialis. 

These  two  sheets  are  blended  together  wherever  the  platysma 
does  not  extend,  and  form  a  dense  and  very  strong  layer  in  the 
superior  half  of  the  external  surface  of  the  sterno-mastoideus. 
There  they  are  very  closely  united  to  the  aponeurosis  on  the  one 
hand,  and  to  the  skin  on  the  other ;  which  explains  the  slight 
extensibility  of  the  latter.  Adipose  vesicles  are  seldom  developed 
in  it,  and  when  abscesses  or  tumours  form  in  it,  although  their 
nature  may  be  acute,  they  are  generally  slow  in  manifesting 
themselves  externally ;  a  circumstance  which  is  explained  by  the 
tenacity  of  the  tissues.  Inferiorly,  these  two  laminae  are  trans- 
formed into  a  simple  lamellated  and  filamentous  cellular  tissue,  in 
which  nervous  filaments  ramify  and  adipose  vesicles  are  some- 
times abundantly  deposited.  It  is  in  the  lamellae  of  the  sheet 
under  the  platysma,  that  the  external  jugular  vein  and  several 


OP  THE   NECK.  181 

branches  of  the  cervical  plexus  are  situated.  It  is  necessary  to 
observe  that  the  fibres  of  the  platysma  itself  are  more  scattered 
and  paler  in  its  inferior  portion  ;  so  that  in  a  great  many  subjects 
they  are  scarcely  distinct  behind  the  clavicle.  The  direction  of  the 
fibres  of  this  muscle  is  upwards  and  inwards,  crossing  the  external 
surface  of  the  sterno-rnastoideus  very  obliquely.  This  last  pecu- 
liarity relates  especially  to  the  jugular  vein,  as  we  shall  see  directly. 

in.  The  Aponeurosis. 

The  fascia  cervicalis  is  much  more  irregular  here  than  in  the 
sub-hyoidean  region.  Nevertheless,  in  emaciated  subjects  and 
those  advanced  in  life,  it  is  generally  very  distinct  and  sometimes 
even  very  strong :  it  is  composed  of  several  sheets,  which  it  is 
possible  to  separate  in  some  places.  Thus,  two  fibrous  laminae, 
which  constitute  the  aponeurosis,  properly  so  called,  envelope 
the  sterno-mastoideus  muscle  ;  at  its  posterior  border  they  reunite, 
and  again  separate  when  they  arrive  at  the  margin  of  the  trape- 
zius.  Those  laminae  which  have  formed  sheaths  for  the  deep- 
seated  parts  of  the  sub-hyoidean  region,  for  the  omo-hyoideus 
muscle,  the  nerves  of  the  brachial  and  cervical  plexus,  and  which 
have  covered  the  scaleni  muscles,  etc.,  afterwards  become 
blended  with  the  internal  surface  of  the  deep  sheet  of  this  apon- 
eurosis. All  these  lamella?  are  very  dense  and  difficult  to  lace- 
rate, and  oppose  the  easy  insulation  of  the  vessels  and  nerves, 
which  they  seem  destined  to  protect.  In  the  inferior  part  of  the 
supra-clavicular  fossa,  there  is  a  considerable  quantity  of  filamen- 
tous cellular  tissue  and  adipose  vesicles  intermingled  with  these 
lamellae.  As  this  species  of  cellular  filter  is  continuous  with 
similar  structures  in  the  hollow  of  the  axilla,  it  naturally  follows 
that  pus,  etc.,  accumulated  beneath  the  aponeurosis,  will  readily 
infiltrate  into  the  latter  region,  by  following  the  sheaths  of  the 
nerves  and  vessels,  or  the  interstices  which  separate  them.  The 
abundance  of  this  cellular  tissue  and  its  diffusion  with  the  aponeu- 
rosis between  the  principal  muscles,  explains  the  tendency  which 
superficial  tumours  and  abscesses  have  to  become  deep-seated; 
and  in  consequence  of  this  arrangement,  we  should  always  give  an 
early  exit  to  purulent  collections  which  may  be  developed  be- 
neath the  skin  of  this  region. 


182  OF    THE    IVECK. 


iv.  The  Muscles. 

This  region  contains  a  considerable  number  of  important 
muscles. 

(  a  )  The  Sterno-Cleido-Mastoideus  is  enveloped  in  a  fibrous 
sheath,  and  the  superior  part  of  its  posterior  margin  is  blended 
with  the  splenius  capitis ;  inferiorly,  it  is  attached  to  the  sternum, 
and  its  internal  tendon  sometimes  gives  considerable  strength  to 
the  sterno-clavicular  articulation,  to  the  anterior  part  of  which  it 
is  applied.  The  external  surface  of  this  muscle  is  covered  by 
the  external  jugular  vein,  the  mastoidean,  auricular,  and  submax- 
illary  branches  of  the  cervical  plexus,  and  the  layers  which  we 
have  just  passed  in  review  ;  and  it  is  frequently  crossed  near  its 
origin  by  the  acromio-clavicular  vein.  Its  deep  surface  rests, 
from  above  downwards,  upon  the  trachelo-mastoideus  (petit 
complexus)  and  the  digastricus,  upon  the  occipital  artery  and 
cervical  plexus,  upon  the  omo-hyoideus  and  scaleni  muscles,  upon 
the  carotid  artery  and  internal  jugular  vein,  which  last  is  seen  a 
little  external  to  its  posterior  border,  and  finally  upon  the  subcla- 
vian  vein.  We  have  already  mentioned  that  the  anterior  margin 
of  this  muscle  serves  as  a  guide  to  the  carotid  artery.  It  is  tra- 
versed in  its  superior  third  by  the  spinal  accessory  nerve. 

(  b  )  The  Trapezius.  The  clavicular  portion  only  of  this 
muscle  is  situated  in  this  region ;  its  fibres  ascend  obliquely  up- 
wards and  backwards.  Included  between  the  two  laminae  of 
the  aponeurosis,  it  is  separated  from  the  skin  merely  by  the  cel- 
lular layer ;  but  its  anterior  surface  is  separated  from  the  omo- 
hyoideus  and  scalenus  posticus  muscles,  from  the  nerves  and 
vessels,  by  an  excavation  of  considerable  depth,  which  is  filled 
by  a  simple  cellular  or  adipose  tissue,  in  which  several  nervous 
and  arterial  branches  ramify.  Its  anterior  margin  is  curved,  its 
concavity  looking  forwards ;  inferiorly,  it  serves  to  limit  the 
incisions  which  are  made  for  the  purpose  of  discovering  the  sub- 
clavian  artery. 

(  c )  The  Levator  Anguli  Scapula.  It  follows  the  posterior 
line  of  the  region,  and  lies  exposed  between  the  two  preceding 
muscles,  where  it  is  about  to  attach  itself  to  the  transverse  pro- 
cesses of  the  vertebrae.  An  adipose  and  cellular  layer,  of  great- 


OF   THE    NECK.  183 

er  or  less  thickness,  separates  it  from  the  trapezius.  Its  anterior 
surface  is  removed  from  the  superior  part  of  the  chest  and  the 
splenii  by  some  very  lax  and  very  extensible  cellular  tissue, 
which  establishes  a  communication  between  the  supra-clavicular 
region  and  the  space  comprised  between  the  serratus  magnus, 
the  intercostales  and  rhomboideus  muscles ;  a  communication 
which  enables  pus,  or  other  fluids,  to  penetrate  from  one  of  these 
regions  to  the  other. 

( d  )  The  Omo-hyoidcus.  This  muscle  frequently  possesses  a 
middle  tendon,  where  it  passes  under  the  sterno-mastoid  mus- 
cle. It  crosses  the  subclavian  vein  and  artery,  the  three  or  four 
last  nerves  which  go  to  form  the  brachial  plexus,  the  two  scaleni 
muscles,  the  phrenic  nerve  and  ascending  cervical  artery,  oblique- 
ly from  below  upwards.  Sometimes,  but  not  most  frequently, 
as  Langenbeck  asserts,*  it  is  united  to  the  posterior  convexity 
of  the  clavicle.  In  this  case,  a  fibrous  process  is  usually  detached 
from  it,  which  fills  the  sinus  resulting  from  the  union  of  the  clav- 
icle, acromion  and  coracoid  process  ;  which  sinus,  or  space,  is 
transformed  into  a  triangle  by  the  muscle  in  question. 

The  omo-hyoideus,  in  ascending  before  the  scaleni,  circum- 
scribes another  very  important  triangle,  which  might  be  called 
the  omo-clauicular  space :  this  space  is  divided  into  two  by  the 
scalenus  anticus. 

In  the  internal  portion,  we  meet  with  the  termination  of  the 
two  jugular  veins,  and  the  subclavian  into  which  they  discharge 
their  blood  ;  the  vertebral  and  inferior  thyroid  vessels ;  the  acra- 
mial  vein,  and  phrenic  nerve  ;  the  supra-scapular,  posterior  and 
ascending  cervical,  internal  mammary  and  subclavian  arteries, 
and  the  origin  of  the  last  cervical  nerves. 

In  the  external,  we  also  find  the  subclavian  vessels,  the  supra- 
scapulary  and  transverse  cervical  veins,  the  posterior  scapular 
artery,  the  last  three  cervical  and  first  dorsal  nerves,  finally  a  part 
of  the  scalenus  posticus  muscle  and  of  the  first  rib. 

With  the  trapezius  and  sterno-mastoideus,  the  muscle  under 
consideration  limits  a  third  triangle,  which  might  be  denomina- 
ted omo-trapezian.  In  this  space  we  find  the  cervical  plexus  and 
the  origin  of  the  branches  given  off  by  it ;  the  fourth  and  fifth 
pairs  which  go  to  the  brachial  plexus ;  divers  branches  of  the 

*  Bibliothtque,  etc.,  vol.  iu,  Cahier  2, 1821. 


OF    THE    NECK, 

transverse  cervical  vessels,  and,  from  above  downwards,  the  ter 
minating  extremity  of  the  splenius  capitis  and  splenius  colli,  the 
angularis  scapulae  and   scalenus  posticus  muscles  ;    lastly,   but 
deeper-seated,  the  trachelo-mastoideus,  and  one  of  the  arches  of 
the  vertebral  artery. 

(e)  The  Scaleni;  Inferiorly,  they  sometimes  form  three  or 
four  distinct  bundles,  but  generally  there  are  only  two,  which  are 
so  arranged  that  the  posterior*  passes  outwards  and  backwards, 
in  order  to  attach  itself  to  the  first  rib,  being  also  prolonged  upon 
the  second :  the  anterior  is  shorter  and  more  rounded,  and  de- 
scends more  internally  and  anteriorly,  in  order  to  become  insert- 
ed into  the  tubercle  of  the  same  rib  by  a  species  of  tendon.  The 
former  is  related  in  a  remote  manner  to  the  levator  scapula?  and 
trapezius,  and  is  covered  anteriorly  by  the  five  nervous  branches 
which  run  to  form  the  brachial  plexus ;  by  the  trunk  of  the  sub- 
clavian artery  and  the  first  twigs  which  depart  from  it,  in  order  to 
pass  externally.  The  latter  is  separated  from  the  scalenus  pos- 
ticus by  a  triangle  the  base  of  which  is  upon  the  first  rib,  and 
in  which  we  find,  at  its  most  inferior  part  and  a  little  anteriorly, 
the  subclavian  artery ;  more  superiorly  and  posteriorly,  the  first 
intercostal  nerve  united  to  the  last  cervical,  then  the  sixth  cervi- 
cal :  still  higher,  a  fleshy  fasciculus  which  sometimes  descends 
from  the  posterior  surface  of  the  scalenus  anticus  upon  the  cos- 
tal extremity  of  the  posticus ;  finally,  above  this  fasciculus,  in  the 
apex  of  the  triangle,  the  first  two  branches  of  the  nerves  which 
go  to  the  brachial  plexus.  Anteriorly,  the  scalenus  anticus  is 
covered,  from  below  upwards,  by  the  subclavian  vein,  by  those 
which  come  from  the  shoulder,  by  the  external  jugular,  some 
nervous  filaments  from  the  cervical  plexus,  the  sterno-mastoideus 
and  the  common  integuments.  It  is  along  the  external  margin 
of  the  scalenus  anticus  that  we  carry  the  finger  when  we  wish 
to  find  the  subclavian  artery,  and  upon  its  internal  border  that  the 
phrenic  nerve  descends.  It  is  this  last  border  which  transforms 
into  a  triangle  the  space  which  separates  it  from  the  longus  colli 
muscle,  and  in  which  the  vertebral  vessels  are  situated. 
We  shall  omit  speaking  of  the  other  small  muscles  of  the  supra- 


*  The  Scalenus  Posticus  embraces  the  Mtdius  and  Posticus  of  English  anatomist? . 
— Transl. 


OF    THE    NECK.  185 

clavicular  region,  such  as  the  inter-transversales,  etc.,  as  they  do 
not  admit  of  any  surgical  application. 

v.  The   Arteries. 

(a)  The  Subclavians.  They  form  two  arches,  the  convexity 
of  which  looks  upwards,  and  in  order  that  their  relations  may  be 
well  understood,  we  will  divide  them  into  three  portions ;  the 
the  first,  within  the  scalenus  anticus;  the  second  between  the 
two  scaleni,  and  the  third  between  these  muscles  and  the  clavicle. 

In  the  first  portion  the  two  subclavian  arteries  must  be  exam- 
ined separately. 

The  right  subclavian  is  the  thickest,  shortest,  and  most  super- 
ficial ;  it  arises  from  the  arteria  innominata,  opposite  to  the  pos- 
terior and  external  part  of  the  sterno-clavicular  articulation,  and 
afterwards  passes  almost  transversely  upon  the  first  rib. 

Its  anterior  surface  is  covered  by  the  phrenic  nerve,  by  pretty 
numerous  filaments  of  the  great  sympathetic,  and  by  the  par  va- 
gum.  All  these  nerves  touch  the  artery,  and  cross  it  nearly  at 
right  angles.  It  is  next  covered  by  the  subclavian  vein  which 
passes  a  little  beyond  it,  during  inspiration,  in  the  omo-clavicular 
triangle  ;  then  by  the  internal  jugular,  which,  as  it  is  about  to  ter- 
minate in  the  preceding,  is  separated  from  the  carotid  by  a  small 
triangular  space,  in  which  we  observe  the  artery  under  consider- 
ation, the  par  vagum  and  some  filaments  from  the  inferior  cervical 
ganglion.  The  sterno-thyroid,  sterno-hyoid,  and  the  sternal  por- 
tion of  the  sterno-mastoid  muscles  remove  all  these  parts  from 
the  superficial  sheet  of  the  aponeurosis,  and  are  themselves  sepa- 
rated from  the  veins  and  artery  by  a  very  strong  fibro-cellular 
lamina  which  is  prolonged  into  the  thorax  upon  the  brachio- 
cephalic  trunk. 

Posteriorly,  it  is  crossed  by  the  recurrent  nerve  and  some  fila- 
ments of  the  great  sympathetic.  It  rests  upon  the  inferior  cervi- 
cal ganglion,  and  more  deeply  upon  the  longus  colli  muscle  and 
the  transverse  process  of  the  first  dorsal  vertebra,  from  which 
parts  it  is  separated  by  adipose  cellular  tissue  and  some  lymphatic 
glands. 

Inferiorly,  this  artery  is  supported  by  the  pleura  and  corres 
ponds  to  the  summit  of  the  lung. 

24 


186  OF    THE    NEC  K. 

Superiorly,  it  is  observed  in  the  triangle  formed  by  the  scalem 
and  longus  colli,  and  is  there  found  in  relation  with  the  vertebral 
and  inferior  thyroid  arteries,  the  first  dorsal  nerve,  and  several 
filaments  of  the  great  sympathetic. 

The  mere  enumeration  of  the  anatomical  relations  of  the  right 
subclavian  artery  on  the  inner  side  of  the  scaleni,  is  sufficient  to 
show  the  danger  and  difficulty  of  applying  a  ligature  around  this 
portion  of  it.  In  fact,  it  would  be  necessary,  in  order  to  perform 
this  operation,  to  cut  the  internal  portion  of  the  sterno-mastoideus, 
and  frequently  the  sterno-hyoid  and — thyroid  muscles ;  then  we 
would  have  to  avoid,  anterior  to  the  artery,  the  vertebral,  inferior 
thyroid  and  internal  mammary  vessels,  the  par  vagum,  phrenic 
nerve,  etc. ;  posteriorly,  the  recurrent  and  great  sympathetic 
nerves,  and  the  superior  intercostal  artery. 

The  only  means  by  which  we  can  avoid  all  these  parts,  with 
the  exception  of  the  muscles,  consists  in  dexterously  dividing  the 
fibrous  sheath  which  envelopes  the  artery  we  are  about  to  tie : 
for  by  this  method  all  the  nerves  will  be  isolated,  since  they  run 
in  the  lamellas  of  this  sheath.  Still  there  would  be  an  obstacle 
to  the  success  of  this  ligature,  in  the  origin  of  the  inferior  thyroid, 
vertebral  and  internal  mammary  arteries,  which  would  interfere 
with  the  formation  of  the  clot,  if  the  thread  was  placed  between 
these  arteries  and  the  scalenus  muscle.  The  danger  would  not 
be  less,  if  the  ligature  was  applied  so  as  to  leave  these  branches  on 
the  acromial  side ;  for  then  it  would  be  too  near  the  innominata 
and  primitive  carotid  for  the  origin  of  the  subclavian  to  be  oblit- 
erated without  exposing  the  subject  to  death  from  haemorrhage. 

On  the  left  side  this  primary  portion  of  the  subclavian  is 
longer,  deeper  and  of  smaller  calibre ;  it  descends  almost  per- 
pendicularly upon  the  arch  of  the  aorta;  the  subclavian  vein 
crosses  it  as  it  passes  towards  the  right ;  the  par  vagum  and 
phrenic  nerves  are  rather  internal  than  anterior  to  it ;  the  thor- 
acic duct  also  crosses  it,  sometimes  posteriorly  and  superiorly, 
at  other  times  anteriorly  and  inferiorly,  in  its  course  to  the  vein 
into  which  it  discharges  itself.  The  carotid  and  left  cardiac 
nerves  run  along  its  inner  side  ;  and,  externally,  it  remains  longer 
in  relation  with  the  pleura  and  lungs  than  the  right  subclavian. 

It  is  important  to  note  all  these  differences,  as  they  shew  us  that 
it  would  be  much  less  dangerous  to  apply  a  ligature  here  than 


OF   THE    NECK.  187 

on  the  right  side,  because,  being  placed  at  a  greater  distance  from 
the  origin  of  the  vessel,  the  adhesive  clot  would  form  without 
difficulty.  It  would  likewise  be  easier  in  its  execution,  for  the 
nerves  do  not  cross  it  as  on  the  right,  but  descend  parallel  to  its 
direction  into  the  chest,  and  might  be  readily  separated.  Never- 
theless, it  must  be  admitted,  that  almost  all  these  advantages  are 
counterbalanced  by  the  greater  depth  and  almost  vertical  direc- 
tion of  the  artery. 

The  two  other  portions  of  the  subclavian  artery  being  perfectly 
similar  on  both  sides,  what  we  shall  say  of  the  one  will  neces- 
sarily apply  to  the  other. 

The  subclavian  artery,  between  the  scaleni,  is  immediately  ap- 
plied, inferiorly,  upon  the  depression  in  the  first  rib ;  posteriorly, 
upon  the  termination  of  the  scalenus  posticus ;  anteriorly,  it  is  a 
little  less  approximated  to  the  scalenus  anticus,  which  is  more 
internal  than  the  posticus :  which  is  owing  to  the  curvature  of 
the  rib :  superiorly  and  slightly  posteriorly,  we  see  the  union  of 
the  first  dorsal  with  the  seventh  cervical  nerve ;  it  is  also  cov- 
ered or  enveloped  by  fibro-cellular  lamellae  of  considerable  thick- 
ness and  density.  It  is  in  this  point  that  we  may  compress  it  in 
two  different  ways,  when  we  wish  to  suspend  the  course  of  the 
blood  in  the  thoracic  member ;  viz.  either  by  pressing  it  from 
above  downwards  upon  the  first  rib,  which  may  be  done  with 
the  thumb  better  than  with  any  species  of  mechanical  instru- 
ment ;  or  from  before  backwards  against  the  anterior  part  of  the 
scalenus  posticus  and  the  transverse  process  of  the  first  dorsal 
vertebra.  In  both  cases  the  compression  is  rendered  more  easy 
and  certain  by  depressing  the  shoulder;  and,  notwithstanding 
John  Bell  is  of  a  contrary  opinion,  it  is  possible  by  this  method 
to  obliterate  the  calibre  of  the  artery.*  We  cannot  deny,  how- 
ever, that  it  will  be  difficult  to  accomplish  this  object  when  the 
clavicle  and  shoulder  are  very  much  elevated,  and  incapable  of 
being  depressed.  Be  this  as  it  may,  the  disposition  of  the  muscles 
is  such  that  it  is  necessary  to  press  the  thumb  from  without  in- 
wards, from  above  downwards,  and  from  before  backwards,  on 
account  of  the  rib  being  inclined  downwards  and  a  little  out- 
wards. 

*  Anatomy,  fcc.  vol.  ii. 


188  OP   THE    NECK. 

It  is  also  in  this  point  that  the  subclavian  artery  may  be  seized 
with  the  greatest  ease  and  certainty ;  and  in  order  to  accom- 
plish it,  we  must,  after  having  lacerated  or  divided  the  different 
cellular  laminae,  carry  the  extremity  of  the  index  finger  along  the 
external  margin  of  the  scalenus  anticus  as  far  as  its  insertion  into 
the  first  rib.  Here,  we  must  seek  for  the  tubercle  of  this  bone, 
which  may  always  be  felt ;  then  by  sliding  the  finger  from  this 
tubercle  backwards  upon  the  anterior  part  of  the  scalenus  pos- 
ticus,  it  will  necessarily  pass  upon  the  artery.  Nothing  then  is 
more  simple  than  to  raise  this  vessel,  by  passing  under  it  an 
aneurisrnal  needle,  either  from  behind  forwards,  or  from  before 
backwards,  always  observing  to  apply  the  finger  upon  the  point 
of  the  artery  opposite  to  that  under  which  the  needle  is  intro- 
duced. This  process  is  so  sure  that  it  would  be  possible  to  ex- 
ecute it  without  the  aid  of  vision.  But  we  should  not  forget  that 
the  artery  is  invariably  the  first  cord  which  is  met  with  behind 
the  tubercle  of  insertion  of  the  scalenus  anticus  muscle. 

Between  the  clavicle  and  this  last  muscle,  the  subclavian  artery 
is  inclined  considerably  downwards,  so  that  the  nearer  we  ap- 
proach the  axilla  the  more  difficult  it  is  to  reach  it.  In  the  first 
place  it  glides  upon  the  first  rib,  then  a  little  upon  the  second  and 
the  external  surface  of  the  scalenus  posticus,  and  at  length  reach- 
es the  superior  portion  of  the  serratus  magnus  muscle.  The  infe- 
rior cord  of  the  brachial  plexus  runs  along  its  superior  or  external 
part,  and  usually  passes  before  the  artery  as  it  enters  the  axilla. 
Anteriorly,  this  portion  of  the  artery  is  covered  by  the  subclavian 
vein,  which  sometimes  ascends  a  little  higher  than  the  artery  in 
the  supra-clavicular  hollow,  near  the  scalenus,  but  inclines  more 
and  more  downwards  in  proportion  as  it  approximates  the  axilla, 
so  that  when  it  passes  under  the  clavicle,  the  vein  is  internal,  the 
nerve  external,  and  the  artery  in  the  middle  and  posteriorly.  In 
the  next  place  it  is  covered  anteriorly  and  superiorly  by  cellular 
tissue,  some  lymphatic  glands,  a  venous  plexus,  the  cervical  apon- 
curosis,  the  platysma  and  the  integuments. 

This  portion  of  the  subclavian  artery  being  included  in  the 
base  of  the  omo-clavicular  triangle,  it  is  necessary,  when  we  wish 
to  apply  a  ligature  around  it,  to  draw  outwards  the  omo-hyoideus 
muscle,  after  having  divided  its  sheath ;  sometimes,  indeed,  we 
are  obliged  to  cut  across  this  small  muscle.  Finally,  the  opera- 


Or   THE    NECK.  189 

lion  should  be  performed  as  near  to  the  scalenus  anticus  as  possi- 
ble, because  in  this  point  the  artery  is  more  superficial,  more  easily 
distinguished  from  the  nerves,  and  less  embarrassed  by  the  other 
organs. 

(  b )  All  the  other  arteries  of  the  supra-clavicular  region  are 
derived  from  the  preceding;  the  vertebral,  internal  mammary 
and  superior  intercostal  originate  within  the  scalenus.  The  first 
was  examined  in  the  infra-hyoidean  region  ;  the  other  two  apper- 
tain to  the  thorax.  All  that  remain  then  to  be  shewn  are  the 
origin  of  the  inferior  thyroid,  the  ascending,  transverse  and  deep 
cervicals,  the  supra-scapulary  and  sometimes  the  acromial  arte- 
ries. 

(  c  )  The  thyroidea  inferior  is  a  little  more  external  than  the 
vertebral,  and  is  situated  behind  the  sterno-mastoid  muscle  on  the 
inner  side  of  the  scalenus  anticus.  It  at  first  ascends  parallel  to 
the  latter  muscle,  and  after  running  about  an  inch,  passes  behind 
the  carotid.  It  gives  off, 

(d)  The  cervicalis  ascendens,  which  continues  the  primitive 
direction  of  the  trunk,  and  soon  applies  itself  upon  the  anterior 
part  of  the  scalenus  anticus,  on  the  inner  side  of  which  it  was 
inferiorly.     It  presents  nothing  interesting  in  a  surgical  point  of 
view. 

(e)  The  Arteria  Supra-Scapularis  is  also  occasionally  given 
off  from  the  trunk  of  the  thyroid :  it  passes  between  the  scalenus 
and  sterno-mastoid  muscles,  then  generally  approximates  the  clav- 
icle, the  direction  of  which  it  follows  ;  so  that  it  might  easily  be 
wounded  in  seeking  for  the  subclavian,  if  we  did  not  proceed  with 
the  greatest  caution.     In  its  course  to  the  coracoid  notch  of  the 
scapula  it  crosses  obliquely  the  nerves  of  the  brachial  plexus,  and 
is  crossed  in  its  turn  by  the  external  jugular  vein  and  the  supra 
and  sub-clavicular  branches  of  the   cervical  plexus.     When  it 
originates  from  the  subclavian  external  to  the  scalenus  muscle,  it 
usually  gives  off  the  acromial  artery,  which,  in  this  case,  immedi- 
ately ascends  upon  the  top  of  the  shoulder. 

(/)  The  Arteria  Tramversalis  Colli  likewise  arises  very  fre- 
quently from  the  trunk  of  the  thyroid  ;  it  curves  outwards  imme- 
diately after  its  origin,  and  passes  in  the  supra-clavicular  depress- 
ion, making  its  way  between  the  same  muscles  as  the  supra-scap- 
ulary, which  it  surmounts  more  or  less.  Passing  transversely  over 


190  OF    THE    i\ECK. 

the  phrenic  nerve  and  the  superior  branches  of  the  brachial  plex- 
us, it  is  crossed  in  its  turn  by  the  external  jugular  and  several  fila- 
ments of  the  cervical  plexus,  and  runs  sometimes  below,  at  other 
times  before  the  omo-hyoideus  ;  it  is  covered  by  the  fascia  cervi- 
calis,  platysma  and  the  skin  ;  its  course  is  tortuous,  and  of  the 
two  branches  which  terminate  it  in  the  posterior  region  of  the 
neck,  one  passes  before  the  levator  scapulae,  the  other  between  this 
muscle  and  the  trapezius.  It  is  seldom  that  this  artery  is  situat- 
ed so  low  down  as  to  be  in  danger  from  the  knife  when  laying 
bare  the  subclavian. 

Finally,  these  secondary  branches  are  of  considerable  impor- 
tance in  surgery  in  relation  to  the  communications  which  they 
establish  with  the  arteries  of  the  shoulder,  thereby  supporting  the 
circulation  in  the  superior  extremity  after  the  principal  trunk  has 
been  obliterated  in  the  omo-clavicular  triangle.  If  however  the 
ligature  is  applied  too  near  their  origins,  they  may  tend  to  turn  off 
the  column  of  blood  and  thereby  prevent  the  formation  of  the 
adhesive  coagulum. 

vi.  The  Veins. 

(a)  The  Subclavian.  The  disposition  of  this  vein  is  not  the 
same  on  both  sides.  On  the  left,  it  does  not  terminate  on  the 
inner  side  of  the  corresponding  scalenus,  but  continues  its  course 
Cowards  the  posterior  part  of  the  opposite  sterno-mastoid  muscle, 
crossing  before  the  left  carotid,  the  trachea,  the  thymus,  when  it 
exists,  and  even  the  right  carotid.  It  is  this  portion  of  the  left  sub- 
clavian vein  which  English  anatomists  call  "  innominata  ;"  it  re- 
ceives the  thymic,  inferior  thyroid,  vertebral  and  internal  mammary 
veins,  etc.,  and  is  found  situated  immediately  behind  the  supra- 
sternal  notch,  and  the  muscles  which  cover  the  posterior  parts  of 
the  sterno-clavicular  articulation. 

In  the  next  place,  the  subclavian  vein  of  each  side  is  at  first 
separated  from  the  fore  part  of  the  artery  by  the  scalenus  anti- 
cus ;  afterwards  it  approximates  it,  then  becomes  immediately  ap- 
plied upon  this  vessel,  and  at  length,  as  it  passes  under  the  clavi- 
cle, it  becomes  quite  internal  or  inferior  to  the  artery.  Anterior- 
ly, it  is  covered  by  the  origin  of  the  sterno-thyroideus,  the  clavi- 
cle, and  then  by  the  subclavius  muscle  ;  its  inferior  side  rests  upon 


OF   THE    NECK.  191 

the  iirst  rib,  the  costo-clavicular  ligament  and  the  superior  sur- 
face of  the  subclavius  muscle :  superiorly,  the  subclavian  vein  is 
covered  only  by  some  cellular  tissue  ;  by  different  veins  terminat- 
ing in  it,  which  we  shall  soon  examine  ;  by  the  aponeurosis  and 
the  fibres  of  the  platysma ;  lastly  by  the  skin. 

This  vein  then  might  be  easily  wounded  when  we  are  about  to 
expose  its  accompanying  artery,  especially  as  all  the  large  veins 
swell  out  considerably,  upon  the  living  subject,  whilst  we  are  per- 
forming an  operation  of  so  great  importance.  It  is  true  that  some 
persons,  Mr.  Lizars*  among  others,  have  proposed  applying  a 
tourniquet  upon  the  arm  with  the  view  of  preventing  this  dila- 
tation, by  stopping  the  venous  circulation  in  the  limb  ;  but,  in 
addition  to  the  inconvenience  which  such  compression  would  pro- 
duce in  case  of  aneurism,  we  imagine  that  it  would  not  accomplish 
the  effect  proposed,  for  the  blood  would  still  continue  to  flow  into 
the  subclavian  through  the  jugulars  and  other  veins  of  the  neck 
and  shoulder.  Consequently,  it  is  much  better  to  content  our- 
selves with  favouring  the  inspirations,  and  pass  the  aneurismal 
needle  from  before  backwards,  and  from  below  upwards,  in  order 
to  be  more  sure  of  avoiding  the  laceration  of  the  veins. 

We  should  not  forget  that  the  thoracic  duct  empties  into  the 
left  subclavian  vein  opposite  to  the  point  where  the  artery  of  the 
same  name  makes  a  curve  in  order  to  pass  between  the  scaleni. 
This  circumstance,  in  fact,  renders  the  ligature  of  the  artery,  on 
this  side,  internal  to  the  scaleni,  much  more  dangerous  than  on  the 
right.  This  circumstance  was  not  overlooked  by  Dr.  Colles  when 
he  applied  a  ligature  on  the  right  carotid  in  18l3;f  but  did  not 
this  surgeon  exaggerate  in  saying  that  this  operation  was  imprac- 
ticable on  the  left  ?  On  the  other  hand,  can  we  admit  with  Mr. 
Shaw,  J  that  it  would  be  preferable,  in  cases  of  aneurism,  to  am- 
putate at  the  shoulder  joint,  than  to  tie  the  artery  within  the  sca- 
leni muscles  ?  Reasoning  from  the  anatomical  disposition  of  the 
parts,  we  think  that  the  extirpation  of  the  arm  would  have  no 
advantage  over  the  ligature  of  the  artery :  besides,  from  the  ope- 
ration of  Colles,  that  of  Dr.  Mott  of  which  we  will  speak  in 
another  place,  and  analogy,  induce  us  to  believe,  that,  if  the  situ- 

*  System  of  Anatomical  Plates,  part  2d,  page  70. 

f  Edinburgh  Medical  &  Surgical  Journal,  No.  41,  Vol.  2. 

t  Manual  of  Anatomy,  page  337. 


192  OF   THE    NECK. 

ation  of  the  disease  should  require  it,  it  would  be  much  better  to 
attempt  this  ligature  than  abandon  the  patient  to  inevitable  de- 
struction. 

(b).  The  External  Jugular.  This  vein  passes  obliquely,  from 
above  downwards  and  from  before  backwards,  in  the  direction  of 
the  trapezius,  and  more  or  less  anterior  to  this  muscle.  It  origin- 
ates by  several  branches  in  the  parotideal  region,  and  falls  into 
the  subclavian  towards  the  middle  of  the  supra-clavicular  excava- 
tion, occasionally  after  having  received  the  veins  of  the  shoulder. 
As  it  descends  it  rests  upon  the  sterno-mastoid  muscle,  which  it 
crosses  very  obliquely ;  its  course,  on  the  contrary,  is  parallel  to 
the  direction  of  the  fibres  of  the  platysma,  which  covers  it.  From 
this  relation  it  follows  that,  when  we  open  this  vessel,  we  should 
divide  the  platysma  transversely  to  the  direction  of  its  fibres,  as 
their  retraction  will  enlarge  the  aperture  and  thereby  admit  of 
the  free  escape  of  the  blood  ;  whereas  if  the  incision  is  made  par- 
allel to  the  course  of  these  fibres,  when  they  contract  they  will 
tend  to  close  the  opening. 

This  vein,  towards  the  middle  of  its  tract,  generally  passes  near 
to  the  different  branches  of  the  cervical  plexus,  especially  the 
ascending  branches,  which  cover  it  or  are  covered  by  it  upon  the 
sterno-mastoid  muscle  ;  for  which  reason  we  should  always  en- 
deavour to  open  this  vein  in  its  inferior  half.  In  the  supra-clavi- 
cular excavation  it  is  separated  from  the  deep-seated  parts  by  the 
cervical  aponeurosis,  so  that  it  is  at  some  distance  from  the  de- 
scending cervical  nerves.  It  is  not  unusual,  however,  to  see  it 
approximate  near  to  the  omo-hyoideus  muscle,  which  it  crosses  at 
an  acute  angle.  As  it  opens  into  the  subclavian  at  a  greater  or 
less  distance  from  the  clavicular  portion  of  the  sterno-mastoid 
muscle,  we  are  obliged,  in  order  to  discover  the  subclavian  artery, 
after  having  cut  through  the  integuments  and  platysma,  to  draw 
the  external  jugular  vein  either  forwards  or  backwards,  with  a 
hook,  and  sometimes  even  to  tie  it  in  two  places  in  order  to  di- 
vide it  afterwards  between  the  ligatures. 

It  is  in  this  space  that  we  compress  it,  when  we  wish  to  draw 
blood  from  it. 

As  it  receives  the  most  part  of  the  external  veins  of  the  crani- 
um, we  conceive  that  it  might  almost  directly  unload  the  sinuses, 
through  the  medium  of  several  emissary  veins.  From  its  cbm- 


OF   THE    NECK.  193 

munication  with  the  deep  seated  jugular  we  may  account  for  the 
flow  ot  blood  being  accelerated  by  the  movements  of  the  lower 
jaw  ;  arid  the  reason  why  practitioners  advise  the  retention  of  the 
breath  while  bleeding  trom  this  vein,  is,  that  the  blood  may  be 
forced  to  remain  longer  in  the  veins  of  the  head  and  neck.  Fi- 
nally, during  this  operation,  M.  Larrey  advises  that  the  pressure 
below  the  orifice  should  not  be  removed  until  a  compress  has 
been  applied  upon  the  latter,  otherwise,  says  he,  the  air  might 
penetrate  into  the  open  mouth  of  the  vein,  and  thus  transform  a 
slight  operation  into  a  wound  suddenly  fatal. 

The  external  jugular  vein  is  generally  single  in  its  inferior  third 
portion  ;  sometimes,  however,  it  is  double  or  triple,  in  which  cases 
its  branches  cannot  be  readily  distinguished  through  the  skin ; 
thereby  rendering  bleeding  from  the  neck  somewhat  difficult. 

(c)  The  Collateral  Veins.  In  this  region  we  find  the  ascend- 
ing and  transverse  cervical,  supra-scapulary,  acromial,  and,  in 
some  subjects,  the  termination  of  the  cephalic.  These  veins 
almost  always  follow  the  direction  of  the  arterial  branches  of  the 
same  name  ;  but  they  are  larger  and  constantly  more  superficial. 
Generally,  the  two  former  open  into  the  internal  jugular,  and  the 
latter  into  the  subclavian  vein.  Previous  to  terminating,  or  when 
they  are  about  to  terminate,  they  occasionally  form  a  species  of 
plexus  external  to  the  sterno-mastoid  muscle  and  above  the  clavi- 
cle ;  which  plexus  may,  as  Langenbeck  has  very  judiciously  ob- 
served, occasion  great  perplexity  in  the  operation  for  securing  the 
subclavian  artery.  To  these  we  may  also  add  some  small  veins 
which  come  from  the  thorax. 

(  d )  The  Internal  Jugular.  Its  termination  alone  appertains 
to  the  supra-clavicular  region.  It  is  situated  posterior  to  the 
sterno-mastoid  muscle,  external  and  anterior  to  the  scalenus  anti- 
cus,  and  at  a  little  distance  from  the  carotid.  Between  it  and 
this  artery  there  is  a  small  elongated  triangle,  in  which  we  usually 
observe  the  par  vagum,  phrenic  and  great  sympathetic  nerves ; 
externally,  we  perceived  it  in  the  hollow  of  the  region  ;  on  the 
left,  it  falls  into  the  subclavian  vein,  a  little  internal  to  the  point 
where  the  thoracic  canal  terminates,  and  is  almost  directly  con- 
tinuous on  the  right  with  the  superior  vena  cava. 

25 


194  OF   THE    NECK. 


vn.  The  Lymphatics. 

The  absorbent  vessels  of  the  neck  and  shoulder,  and  a  part  of 
those  of  the  exterior  of  the  chest  enter  this  region.  We  also 
find  in  it  a  very  great  number  of  lymphatic  glands,  which  may 
be  divided  into  those  situated  under  the  sterno-mastoid,  behind 
the  clavicle,  and  those  which  fill  the  supra-clavicular  cavity. 
When  the  former  become  tumefied,  they  may  be  mistaken  for  an 
aneurism  of  the  arteries  in  their  immediate  neighbourhood  ;  the 
latter  can  seldom  occasion  mistakes  of  the  like  nature.  The  for- 
mer will  frequently  compress  the  carotid,  internal  jugular  and 
subclavian  vessels ;  the  latter  will  produce  compression  of  the 
nerves. 


viii.  The  Nerves. 


(a)  The  Cervical  Plexus  is  almost  entirely  covered  by  the 
sterno-mastoid  muscle,  and  lies  upon  the  anterior  and  external 
portion  of  the  scaleni.  In  the  first  place,  we  observe  the  as- 
cending branches,  one  of  which,  the  submaxillary,  makes  a  turn 
from  under  the  sterno-mastoid  upon  the  external  surface  of  this 
muscle,  and  soon  enters  the  sub-hyoidean  region  :  it  is  crossed  by 
the  external  jugular.  Another  makes  a  similar  curve,  but  ascends 
into  the  parotideal  region :  this  is  the  anterior  auricular.  A  third, 
which  is  the  mastoid  branch,  runs  perpendicularly  behind  this 
muscle,  which  at  first  conceals  it,  and  thus  rises  to  the  summit  of 
this  region.  The  first  anastomoses  particularly  with  the  portio 
dura  (facial) ;  the  second  with  the  facial,  superficial  temporal, 
and  filaments  from  the  frontal,  and  the  third  unites  principally 
with  the  occipital. 

The  spinal  (accessory)  nerve  is  the  most  remarkable  among 
the  descending  branches.  It  almost  always  perforates  the  sterno- 
mastoid  from  above  downwards,  descends  between  the  levator 
scapulae  and  trapezius  muscles  and  ramifies  in  the  latter.  It  con- 
stitutes the  principal  external  respiratory  nerve  of  Chas.  Bell. 
We  must  avoid  wounding  it  when  we  bleed  from  the  jugular 
vein,  or  remove  tumours  from  this  region.  It  is  always  some- 


OF   THE    NECK.  195 

what  deeply  situated  behind  the  aponeurosis  when  it  enters  the 
trapezius  muscle. 

The  supra  and  sub-clavicular,  supra-acromial,  descending  and 
deep  cervical  filaments,  diverge  under  the  aponeurosis,  between 
the  trapezius  and  sterno-mastoid  muscles,  and  are  situated,  for  the 
most  part,  before  the  omo-hyoideus,  but  further  back  than  the 
external  jugular.  We  are  obliged  to  divide  several  of  them,  in 
operating  upon  the  subclavian  artery,  because  it  is  difficult  to  iso- 
late them,  on  account  of  the  filamentous  and  dense  cellular  tis- 
sue which  envelopes  them. 

(  b  )  The  Phrenic.  This  nerve  requires  particular  attention 
in  the  performance  of  operations,  in  order  that  it  may  escape 
injury.  It  Arises  from  the  third  and  fourth  cervical  nerves,  and 
seems  occasionally  to  arise  from  the  cervical  plexus.  It  crosses 
the  branches  which  go  to  the  brachial  plexus,  and  descends  upon 
the  anterior  part  of  the  scalenus  anticus,  buried  under  the  sterno- 
mastoid  muscle,  on  the  outer  side  of  the  internal  jugular  vein. 
As  it  enters  the  chest,  it  passes  between  the  subclavian  artery  and 
vein,  opposite  to  the  point  of  union  of  the  first  two  portions  of 
the  latter  vessel;  so  that  this  is  one  of  the  branches  which  would 
be  most  exposed  in  the  ligature  attempted  by  Colles.  This  nerve 
being  the  chief  source  of  motion  to  the  diaphragm,  we  conceive 
that  its  division,  by  suspending  the  contractions  of  this  muscle, 
would  greatly  derange  the  respiratory  function.  It  is  the  inter- 
nal respiratory  nerve  of  Chas.  Bell. 

(  c  )  The  External  or  Posterior  Thoracic.  This  cord  arises 
from  the  posterior  part  of  the  fourth  and  fifth  cervical  branches 
anterior  to  the  scalenus  posticus,  and  terminates  in  the  serratus 
magnus.  It  also  enters  into  the  system  of  the  respiratory  nerves 
of  Chas.  Bell. 

(  d  )  The  Nerves  of  the  Brachial  Plexus.  Included  between 
the  two  scaleni,  they  are  so  arranged  that  the  sixth  cervical  pair, 
as  well  as  the  cord  resulting  from  the  junction  of  the  seventh 
with  the  first  dorsal  nerve,  are  separated  from  the  others  by  the 
fleshy  fasciculus  (Scalenus  minimus  of  Scemmering)  which  passes 
from  the  posterior  surface  of  the  scalenus  anticus  to  the  an- 
terior part  of  the  costal  extremity  of  the  scalenus  posticus. 
Hence  it  follows  that  the  subclavian  artery  and  the  two  first 


106  OJb'    THE    NECK. 

cords  are  in  a  distinct  space,  in  a  complete  triangle,  the  base  of 
which  is  represented  by  the  first  rib ;  and  that  the  other  cords 
are  not  so  much  isolated,  notwithstanding  they  are  also  included 
in  a  triangular  space,  the  base  of  which  is  elongated  and  rests 
upon  the  anterior  surface  of  the  scalenus  posticus.  It  has  oc- 
curred more  than  once,  that  even  skilful  surgeons  have  applied 
a  ligature  upon  one  of  the  two  first  cords  instead  of  the  artery. 
This  mistake  may  be  avoided  by  recollecting  that  we  always 
meet  w^ith  the  artery  first  in  departing  from  the  tubercle  of  the 
rib  ;  that  the  first  nerve  is  both  more  elevated  and  more  posterior ; 
that  it  rests  upon  the  muscle,  whilst  the  artery  is  actually  in  con- 
tact with  the  bone ;  that  the  artery  is  of  a  reddish  pale  colour 
and  flattened  upon  the  body  which  supports  it ;  whilst  the  nerve 
is  of  a  reddish  white,  harder,  more  cylindrical,  etc.  All  these 
nerves  approximate  each  other  as  they  descend ;  so  that  at  the 
moment  they  are  about  passing  under  the  clavicle,  they  form  a 
sort  of  bundle,  the  arrangement  of  which  is  not  always  the  same. 
In  this  tract  they  are  only  separated  from  the  summit  of  the 
thorax  and  the  inferior  part  of  the  neck,  by  cellular  tissue  and 
some  lymphatic  glands.  The  levator  scapulae  and  omo-hyoideus 
run  along  their  superior  and  external  portion,  the  latter  muscle 
being  the  most  superficial.  They  are  crossed  by  the  supra- 
scapulary  and  transverse  cervical  arteries  and  veins,  and  the 
external  jugular ;  finally,  they  are  covered  by  lymphatic  glands 
and  the  descending  nerves  of  the  cervical  plexus,  by  much  cellu- 
lar tissue,  the  aponeurosis,  the  platysma  and  integuments.  On 
approaching  the  axilla,  the  most  inferior  cord,  which  was  at  first 
situated  above  and  behind  the  artery,  upon  the  first  rib,  at  length 
places  itself  before  this  vessel,  always  remaining  a  little  to  its 
outer  side.  The  sixth  cervical  pair  also  approximates  close  to 
this  artery,  and  even  touches  it  as  it  passes  under  the  clavicle, 
when  it  is  sometimes  situated  behind  it. 

The  nervous  cords  which  we  have  just  examined,  before  they 
enter  the  cavity  of  the  axilla,  give  off,  besides  the  posterior 
thoracic,  some  other  branches  (the  anterior  thoracic  nerves) 
which  are  generally  distributed  to  the  anterior  part  of  the  thorax. 
One  of  these  branches,  more  constant  than  the  others,  should  be 
particularly  noticed :  it  is  that  which  generally  arises  by  two 


OF    THE    NECK.  197 

roots,  one  of  which  passes  behind,  the  other  before  the  subcla- 
vian  artery  and  unite,  forming  a  species  of  loop,  which  we  should 
be  careful  to  exclude  from  the  ligature  applied  upon  this  vessel. 

(e  )  The  Par  Vagum.  (Pneumo-Gastric.)  Properly  speak- 
ing, this  nerve  does  not  appertain  to  the  supra-clavicular  region 
until  it  is  on  the  point  of  entering  the  cavity  of  the  thorax.  On 
the  right  side,  previous  to  passing  before  the  subclavian  artery,  it 
is  situated  opposite  the  vertebral  vessels,  which  separate  it  from 
the  anterior  part  of  the  transverse  processes  and  the  external 
portion  of  the  longus  colli  muscle.  It  is  separated  from  the  tra- 
chea by  the  carotid,  from  the  scalenus  anticus  by  the  jugular,  is 
covered  by  the  subclavian  vein,  by  the  root  of  the  sterno-thyroid, 
sterno-hyoid,  and  sterno-mastoid  muscles,  then  by  the  sterno- 
clavicular  articulation.  It  is  here  that  the  inferior  laryngeal 
(recurrent)  nerve  is  detached  from  it,  anterior  to  the  artery, 
around  which  it  makes  a  turn,  so  that  it  ascends  from  behind  this 
vessel  towards  the  oesophagus  and  trachea :  this  species  of  ner- 
vous circle  would  require  the  strictest  attention,  if  we  should 
attempt  to  tie  the  subclavian  artery  on  the  inner  side  of  the 
scalenus. 

On  the  left,  the  relations  of  the  par  vagum  differ  somewhat 
from  those  which  have  just  been  described.  It  is  much  more 
deeply  seated  ;  it  crosses  the  vertebral  artery  very  obliquely,  and 
places  itself  at  its  internal  part ;  it  runs  between  the  carotid  and 
subclavian  arteries  without  passing  before  the  latter ;  and  lastly, 
it  does  not  give  off  the  recurrent  until  it  reaches  the  arch  of  the 
aorta. 

(/)  The  Great  Sympathetic.  Strictly  speaking,  the  middle 
and  inferior  ganglia  appertain  to  this  region  ;  but  it  appears  more 
proper  to  defer  treating  of  the  latter  until  we  come  to  describe 
the  cavity  of  the  thorax ;  and,  as  the  former  does  not  always 
exist,  it  is  useless  to  take  up  our  time  in  relation  to  it.  We  have 
then  to  speak  only  of  the  filaments  which  originate  from  these 
ganglia  in  order  to  form  a  species  of  plexus  around  the  sub- 
clavian vessels.  The  most  of  these  filaments  proceed  from  the 
middle  ganglion ;  two  or  three  ascend  from  the  inferior,  and  all 
of  them  intermingle  with  the  cardiac  twigs  of  the  superior  gang- 
lion, and  with  other  filaments  derived  from  the  recurrent,  etc. 
In  this  manner  a  complicated  net-work  is  formed  before  and  be- 


198  OF    THE    NECK. 

hind  the  arterial  trunk  ;  but  the  branches  which  collect  to  form 
this  nervous  interlacement  are  so  small  and  numerous,  that  it  is 
almost  impossible  to  avoid  wounding  some  of  them  in  the 
attempt  to  lay  bare  the  first  portion  of  the  subclavian  artery. 
This  laesion  seems  to  be  the  principal  cause  of  the  accidents 
which  follow  the  operation,  on  account  of  the  disturbance  which 
it  must  occasion  in  the  functions  of  the  heart. 

ix.  The  Skeleton. 

The  skeleton  of  the  supra-clavicular  region  is  composed  of  the 
clavicle  and  first  rib.  These  two  bones  leave  between  them  a 
double  triangular  space  with  which  it  is  of  importance  to  be  well 
acquainted.  Thus,  let  us  suppose  the  shoulder  drawn  very  much 
backwards  and  elevated  as  much  as  possible,  the  plane  of  the 
triangle  will  be  perpendicular ;  that  is  to  say,  the  clavicle  will  be 
superior  and  the  rib  inferior.  But  if  the  clavicle  is  very  much 
depressed  and  at  the  same  time  brought  forward  as  much  as 
possible,  the  plane  of  this  triangle  will  be  horizontal.  The  apex 
of  this  triangular  space  is  always  at  the  sterno-clavicular  articula- 
tion, and  its  base  is  represented  by  an  arbitrary  line  drawn  from 
the  transverse  process  of  the  first  dorsal  vertebra  to  the  posterior 
part  of  the  clavicle,  opposite  to  the  coracoid  process,  and  is 
naturally  filled  from  within  outwards,  and  from  before  backwards ; 

(  a  )  By  the  costo-clavicular  ligament,  which  is  so  disposed 
that  it  promptly  restrains  the  movements  of  the  clavicle  up- 
wards and  forwards,  and  which  is  separated  from  the  subcla- 
vian artery  only  by  a  cellulo-adipose  layer,  generally  of  slight 
thickness ; 

( b )  By  the  subclavius  muscle,  which  is  prolonged  upon  the 
inferior  surface  of  the  clavicle  almost  to  the  point  where  this 
bone  receives  the  insertion  of  the  coraco-clavicular  ligaments. 
Its  superior  surface  is  covered  by  a  fibro-cellular  expansion,  which 
is  afterwards  spread  over  the  vein,  artery  and  nerves,  and  is 
finally  lost  in  the  cellular  tissue  of  the  supra-clavicular  excava- 
tion. This  lamina,  which  is  attached  to  the  whole  extent  of  the 
posterior  margin  of  the  clavicle,  is  continuous  on  the  other  part 
with  the  costo-clavicular  ligament ; 

(  c )   By  the  subclavian  vessels  and  nerves  arranged  in  the 


OF    THE    NECK.  199 

following  manner  :  first  the  vein,  next  the  artery  which  is  more 
posteriorly ;  then  the  most  inferior  cord  of  the  brachial  plexus, 
slightly  covering  the  anterior  part  of  the  artery ;  lastly  the 
other  branches  of  this  plexus  situated  more  externally  and 
posteriorly.  From  this  disposition  it  follows  that  the  subclavian 
artery  is  covered  almost  entirely  by  the  vein  which  is  internal, 
and  by  a  nerve  which  is  external.  Langenbeck,  therefore,  is  in 
error,  when  he  affirms  that  the  artery  is  more  superficial  than 
the  nerve ;  at  least  we  have  generally  found  its  relations  as  just 
stated. 

(  d  )  More  externally,  this  space  is  filled  only  by  cellular 
tissue,  fat,  lymphatic  glands,  nervous  filaments  and  vascular 
ramifications.  It  is  through  this  part  that  morbid  fluids,  formed 
in  the  supra-clavicular  region,  beneath  the  aponeurosis,  pene- 
trate with  the  greatest  facility  into  the  axilla  and  behind  the 
thorax. 

As  the  artery  and  vein  are  fixed  in  the  place  which  they 
occupy  by  the  fibrous  lamina  indicated  above,  it  follows  that,  in 
certain  positions  of  the  shoulder,  these  vessels  may  be  so  com- 
pletely compressed  as  to  obliterate  their  calibre.  Thus,  by  push- 
ing the  shoulder  downwards  and  forcibly  backwards,  the  com- 
pression may  be  so  firm  as  to  suspend  the  circulation  in  the  arm 
entirely,  and  every  body  knows  that  in  this  way  we  can  imme- 
diately stop  the  pulsation  at  the  wrist.  There  are  some  persons 
in  whom  this  remark  my  be  usefully  applied  in  order  to  explain 
certain  apparent  anomalies  of  the  circulation.  For  example,  an 
individual  may  lie  in  such  a  manner  that  the  weight  of  the  body 
bears  principally  upon  the  anterior  part  of  the  shoulder ;  in  which 
case  the  pulse  might  not  be  perceptible  at  the  wrist.  This  cir- 
cumstance would  greatly  embarrass  the  physician,  if  he  did  not 
reflect  on  this  state  of  mechanical  obliteration  of  the  subclavian 
occasioned  by  the  pressure  of  the  clavicle  and  its  muscle  upon  it. 
Such  an  occurrence  has  presented  itself  twice  to  our  notice. 

As  the  nerves  pass  through  a  wider  part  of  the  triangle,  their 
compression  must  necessarily  be  less  prompt  and  less  complete. 
Nevertheless,  when  the  bones  are  very  much  approximated,  and 
continue  so  for  some  moments,  a  greater  or  less  degree  of  numb- 
ness soon  indicates  that  the  nerves  are  compressed. 

From  what  has  just  been  observed,  we  find  that  these  organs 


200  OF   THE    NECK. 

will  be  the  more  freeand  will  fulfil  their  functions  better,  in  propor- 
tion as  the  shoulder  is  carried  upwards  and  forwards ;  but  we 
also  see  that,  in  this  position,  the  artery  will  be  at  a  greater  depth, 
and  consequently  exposed  with  greater  difficulty.  Unfortunate- 
ly it  is  most  frequently  in  such  cases  that  it  becomes  necessary 
to  tie  the  subclavian. 

In  fact,  aneurysmal  tumours  of  the  axilla,  which  do  not  admit 
of  the  application  of  a  ligature  anterior  to  the  clavicle,  never  be- 
come much  enlarged  without  pushing  the  shoulder  in  the  direc- 
tion just  indicated.  Otherwise,  whenever  the  disease  does  not 
prevent  it,  we  should  always  depress  the  shoulder,  drawing  it 
forwards.  It  is  this  position  also  which  enables  us  to  compress 
the  artery  against  the  first  rib,  if  it  could  be  adopted  during  the 
performance  of  the  greater  proportion  of  the  operations  which 
such  compression  requires,  in  amputations,  for  example. 

It  is  proper  to  remark,  that  when  this  double  triangle  is  forci- 
bly contracted,  (that  is  to  say,  when  the  clavicle  is  curried  very 
Much  downwards  and  backwards,)  the  clavicle  acts  upon  the  first 
rib  as  a  lever  of  the  first  order,  and  is  only  restrained  from  luxa- 
tion forwards  by  the  sterno-clavicular  ligament.  When,  howe- 
ver, it  is  expanded  (the  shoulder  brought  very  much  forwards  and 
upwards)  the  clavicle  forms  a  lever  of  the  second  order,  and  then 
the  costo-clavicular  ligament  as  strongly  opposes  its  luxation 
backwards  as  the  ligaments  which  appertain  to  the  articulation. 
We  will  resume  the  consideration  of  this  subject  when  we  come 
to  treat  of  the  sternal  region,  and  will  speak  of  fractures  of  this 
bone  when  describing  the  axillary  region. 

The  first  rib  is  important,  as  regards  its  anatomical  dispositions, 
in  several  points  of  view.  Its  cartilage  is  broad,  thick  and  very 
strong ;  it  is  also  very  short,  and.  if  I  may  so  say,  incorporates 
the  rib  with  the  sternum.  These  are,  here,  so  many  elements  of 
strength  and  resistance.  Its  vertebral  extremity  presents  a 
rounded  head,  and  not  two  plane  articulating  surfaces  ;  its  tuber- 
cle is  not  applied  to  the  transverse  process ;  the  ligaments  which 
connect  this  extremity  to  the  spine  are  weaker,  and  less  fibrous 
than  those  of  the  following  ribs :  here,  these  are  so  many  elements 
of  mobility,  and  it  is  this  contrary  arrangement  of  the  two  ex- 
tremities of  the  first  rib  which  has  given  rise  to  the  opposite 
opinions  of  Haller  and  M.  Magendio.  The  first  of  these  physi 


OP   THE    NECK.  201 

ologists  maintains  that  the  first  rib  is  almost  immoveable,  or  at 
least  that  its  mobility  is  comparatively  much  less  than  that  of  tfce 
other  ribs,  and  thence  concludes  that  it  serves  as  a  fixed  point  to 
the  intercostal  muscles  during  inspiration.  M.  Magendie,  on  the 
contrary,  thinks  that  it  is  more  moveable  than  all  the  others,  and 
that  it  is  elevated,  during  inspiration,  like  all  those  which  are  below 
it.  It  is  not  for  us  to  decide  this  question;  but  we  are  of  opinion 
that,  whilst  the  strength  of  the  cartilage  and  the  shortness  of  the 
bone  give  weight  to  the  idea  of  Haller,  they  do  not  prevent  the 
mobility  of  this  rib  upon  the  spine,  nor  the  elevation  of  the  tho- 
rax en  masse ;  so  that  if  the  first  rib  is  actually  the  fixed  point 
for  the  muscular  actions,  it  must  be  so  only  through  the  medium 
of  the  scaleni  muscles,  the  anterior  especially. 

In  tracing  this  rib  from  the  sternum  towards  the  vertebra  to 
which  it  is  attached,  its  superior  surface  is  at  first  broad,  horizon- 
tal and  very  slightly  elevated ;  the  costo-clavicular  ligament  is 
attached  to  it  obliquely  from  within  outwards,  and  from  the  pos- 
terior towards  the  anterior  margin :  whence  results  a  gutter 
circumscribed  by  the  clavicle  and  rib,  and  excavated  upon  the 
posterior  surface  of  the  ligament,  which  then  supports  the  sub- 
clavian  vein  and  artery.  Afterwards,  this  surface  inclines  slight- 
ly outwards  and  backwards,  and  presents,  in  this  direction,  a 
superficial  depression,  in  which  the  vein  lies.  Behind  this  slight 
depression  we  observe  the  tubercle  to  which  the  scalenus  anti- 
cus  is  attached,  then  the  groove  in  which  the  artery  is  lodged. 
This  tubercle  is  a  little  broader  internally  than  externally,  which 
is  owing  to  this  arterial  groove  being  almost  transversal,  whilst 
the  venous  depression  is  oblique  posteriorly.  Here,  the  rib  is 
a  little  narrower.  Finally,  the  rest  of  this  surface  again  becomes 
broader,  rises,  and  resumes  the  horizontal  position ;  it  receives 
the  attachment  of  a  part  of  the  scalenus  posticus. 

In  the  supra-clavicular  region  we  penetrate  through  the  fol- 
lowing parts  previous  to  reaching  the  first  rib :  1st.  The  skin ; 
2d.  a  cellular  layer  of  moderate  thickness  ;  3d.  the  platysma,  but 
in  the  anterior  half  of  the  region  only ;  4th.  a  thin  lamellated 
cellular  tissue,  which  supports  the  platysma,  through  which  the 
external  jugular  vein  and  some  nervous  filaments  take  their 
course ;  5th.  the  aponeurosis,  which  splits  anteriorly  and  poste- 
riorly in  order  to  envelope  the  sterno-mastoid  and  trapezras  mus- 

26 


OF    THE    NECK. 

cles ;  6th.  much  cellular  tissue,  fat,  lymphatic  glands,  the  nerv<.> 
of  the  cervical  plexus,  secondary  veins  and  arteries ;  quite  infe- 
riorly,  the  subclavian  vein,  the  omo-hyoideus  muscle ;  7th.  the 
phrenic  nerve,  the  scalenus  anticus  muscle  ;  8th.  the  nerves  of  the 
brachial  plexus,  the  subclavian  artery;  9th.  the  scalenus  posti 
cus  and  the  bone. 

ART.    II.       POSTERIOR   PART   OF   THE    KECK. 

The  posterior  region,  or  nape,  of  the  neck,  is  bounded ;  supe- 
riorly, by  the  occipital  protuberance,  transverse  ridge  and  mas^ 
toid  process  ;  inferiorly,  by  a  transverse  line  drawn  from  the 
superior  angle  of  one  scapula  to  that  of  the  other  along  the  cervi- 
cal margin  of  these  bones,  and  laterally  by  the  supra-clavicular 
region,  or  a  line  dropped  from  the  mastoid  process  upon  the 
acromio-clavicular  articulation. 

This  region  is  rounded  and  narrow  in  the  middle  ;  broader  and 
projecting  backwards,  superiorly ;  plane  and  still  broader  inferi- 
orly, and  of  various  lengths  and  thicknesses  in  different  subjects. 
These  peculiarities  generally  depend  upon  its  degree  of  promi- 
nence, the  elevation  or  depression  of  the  shoulders,  and  the 
developement  of  the  muscles  and  other  soft  parts. 

Upon  its  surface  we  observe,  from  above  downwards,  the  ex- 
ternal occipital  protuberance,  which  is  more  prominent  in  some 
individuals  than  in  others,  and  corresponds  with  the  Torcular 
Hierophili  within  the  cranium ;  below  this,  a  triangular  excava- 
tion, bounded  laterally  by  an  eminence  occasioned  by  the  com- 
plexi  muscles.  This  hollow  is  called  the  pit  of  the  neck,  and  is 
the  place  where  issues  are  usually  made :  it  is  bounded  inferior- 
ly by  the  spinous  process  of  the  axis  (dentatus).  It  corresponds 
to  the  space  which  separates  the  os  occipitis  from  the  atlas,  and 
an  instrument  introduced  through  it  might  easily  wound  the  me- 
dulla oblongata.  More  inferiorly  we  observe  merely  a  simple 
furrow,  and  that  only  when  the  head  is  in  extension  ;  this  furrow 
is  the  continuation  of  the  preceding  triangular  excavation.  The 
muscles  likewise  form  an  eminence  on  each  side,  but  this  is  only 
seen  when  the  furrow  exists,  and  during  their  contraction.  In 
the  bottom  of  this  furrow  we  with  difficulty  feel  the  spinous  pro- 
cesses of  the  cervical  vertebrae.  At  the  most  inferior  part  of  the 


OF    THE    NECK.  203 

region  we  see  the  spine  of  the  seventh  vertebra,  which  generally 
makes  a  very  distinct  prominence. 

CONSTITUENT    PARTS. 

i.  The  Skin. 

Its  thickness  is  considerable,  more  so  upon  the  median  line  and 
muscular  eminences ;  a  little  less  anteriorly  or  laterally ;  and  its 
resistance  is  very  great ;  which  accounts  for  the  agonizing  pains 
attendant  upon  furunculous  tumours  developed  in  it.  It  is  very 
elastic,  almost  inextensible,  possesses  but  little  vascularity,  and  is 
almost  entirely  composed  of  the  fibrous  element.  It  is  to  this 
predominance  of  the  solids  over  the  fluids,  in  the  skin  of  the  neck, 
that  many  attribute  the  infrequency  of  acute  or  chronic  pustu- 
lar affections,  dartres,  in  short  of  cutaneous  exanthemata  in 
this  region.  This,  however,  is  not  the  fact,  for  we  observe  her- 
pes iurfuraceus  (dartres  fmfuracees),  porrigo  (prurigo),  etc., 
as  frequently  in  this  situation  as  elsewhere.  It  is  sometimes 
wrinkled  transversely,  especially  in  old  people,  and  those  who 
have  lost  much  of  their  embonpoint.  We  do  not  observe  papil- 
lary wrinkles  upon  it ;  but  we  frequently  perceive  in  it  points  of 
a  determinate  figure,  which  correspond  to  the  areolae  of  its  inter- 
nal surface.  The  hairs  which  cover  the  skin  above,  seldom  de- 
scend lower  than  the  dentatus  ;  the  rest  of  its  surface  is  destitute 
of  them.  It  does  not  contain  many  sebaceous  follicules,  at 
least  they  are  distinguished  with  difficulty  upon  the  median  line. 
This  skin  generally  becomes  more  adherent  the  lower  it  descends ; 
nevertheless,  it  is  commonly  sufficiently  moveable  to  allow  us  to 
pinch  up  folds  of  it  of  considerable  thickness,  when  we  wish  to 
introduce  a  seton  through  it,  and  for  this  purpose  the  middle  of 
the  region  is  to  be  preferred,  as  well  as  on  account  of  the  dress- 
ings. When  we  wish  to  form  an  issue,  however,  we  give  the 
preference  to  the  pit  of  the  neck,  because  there  is  in  this  fossette 
a  great  quantity  of  cellular  tissue ;  the  form  of  it  is  very  well 
adapted  for  the  establishment  of  a  drain ;  the  cellular  tissue  passes 
directly  upon  the  membranes  of  the  encephalon ;  indeed,  every 
circumstance  seems  to  indicate  that  an  issue,  applied  in  this  situa- 
tion, will  act  much  more  efficaciously  upon  the  brain  and  its  me- 
ninges,  than  if  established  elsewhere. 


«*    THE    NECK. 

ii.  The  Subcutaneous  Cellular  Layer. 

This  layer  is  generally  thin,  formed  of  lamella?  and  filaments, 
dense  and  firmly  adherent  to  the  skin,  so  that  when  we  nip  up  a 
portion  of  the  latter,  in  order  to  pass  a  seton  needle  through  it, 
the  cellular  tissue  is  always  included  within  the  gripe.  Those  of 
its  lamellae  which  are  nearest  to  the  dermis  contain  numerous 
adipose  cells,  which  sometimes  form  a  cushion  of  considerable 
thickness.  The  other  surface  of  this  species  of  membrane  is 
more  uniform,  and  but  loosely  united  to  the  aponeurosis ;  but  it 
adheres  pretty  firmly  to  the  ligamentum  nuchae  (cervical  l(ga- 
ment),  with  which  it  seems  to  be  blended.  It  is  in  this  layer  that 
pus  forms,  in  the  erysipelatous  inflammations  of  the  posterior 
part  of  the  neck.  In  these  cases,  the  great  thickness  of  the  skin 
and  its  slight  degree  of  extensibility  afford  much  resistance  to  the 
fluid  which  tends  to  accumulate  beneath  it ;  hence  it  is  that  these 
abscesses  are  seldom  circumscribed  in  a  well  defined  manner, 
and  that  they  promptly  extend  in  different  directions.  It  is  with 
the  view  of  avoiding  the  accidents  which  might  result  from  the 
diffusion  of  these  collections,  that  we  are  recommended  to  let 
out  the  morbid  fluids  so  soon  as  they  have  formed.  Unfortunate- 
ly it  is  not  always  easy  to  seize  upon  the  opportune  moment ;  for 
generally,  it  is  very  difficult  to  detect  the  fluctuation.  This  cel- 
lular layer  is  usually  dry,  and  encloses  but  a  small  number  of 
vessels  and  nervous  filaments. 

in.  The  Aponeurosis. 

In  the  supra-clavicular  region  we  mentioned  that  the  cervical 
aponeurosis  separated  into  two  sheets  when  it  reached  the  mar- 
gin of  the  trapezius.  These  two  sheets  again  become  blended 
upon  the  median  line,  after  having  enveloped  this  muscle.  In 
thus  terminating,  they  concur  in  the  formation  of  the  cervical  lig- 
ament (Ligamentum  Nuchal),  which,  on  the  other  side,  is  the 
common  rendezvous  of  all  the  intermuscular  cellular  laminae. 
In  man,  this  ligament  is  reduced  to  a  simple  fibro-cellular  band, 
which  extends  from  the  os  occipitis  to  the  last  cervical  vertebra, 
and  unites  the  spinous  processes  of  the  neck  to  the  skin.  It 
consequently  separates  all  the  muscles  of  the  right  side  from  those 


OP   THE   NECK. 

of  the  left.  In  quadrupeds,  especially  graminiverous  animals,  the 
cervical  ligament  is  very  strong  and  elastic :  whence  it  follows 
that  the  head  of  these  animals  is  naturally  elevated,  whenever 
the  flexor  muscles  are  in  a  state  of  relaxation.  Upon  the  super- 
ficial lamina  of  this  aponeurosis  some  nervous  filaments  from  the 
posterior  cervical  branches  ramify.  This  lamina  is  thin  and  firm- 
ly adherent  to  the  trapezius  muscle ;  but  its  external  surface  ad- 
heres but  slightly  to  the  subcutaneous  layer :  therefore  nothing  is 
more  easy  than  to  fold  the  skin  of  the  posterior  part  of  the  neck, 
and  comprise  in  the  duplicature  the  cellular  tissue  which  lines  it, 
without  running  the  risk  of  wounding  the  aponeurosis. 

iv.  The  Muscles. 

They  are  very  numerous  and  arranged  in  strata.  Some  of 
them  extend  throughout  the  whole  length  of  the  region ;  others, 
on  the  contrary,  only  traverse  it  in  part.  Among  the  former, 
are, 

(  a)  The  Trapezii.  These  muscles  are  united  at  the  median 
line  by  means  of  their  aponeurosis,  which  grows  broader  as  it 
descends,  in  order  to  form  the  fibrous  rhombus  (losange  fibreux), 
the  centre  of  which  is  at  the  spine  of  the  seventh  cervical  verte- 
bra. They  form  the  first  stratum,  which  is  separated  from  the 
skin  by  the  aponeurosis  and  subcutaneous  layer  only. 

(  b  )  The  Splenius  cervicis  et  capitis,  which  form  a  second 
layer,  separated  from  the  preceding  by  an  aponeurotic  lamina  of 
considerable  strength,  and  by  a  portion  of  the  rhomboideus  infe- 
riorly.  In  passing  towards  the  head,  these  muscles  leave  be- 
twen  them  a  triangular  space,  the  apex  of  which  corresponds  to 
the  middle  of  the  neck,  and  in  which  the  trapezius  rests  imme- 
dirately  upon  the  complexi.  It  is  in  the  upper  part  of  this  space 
that  the  occipital  artery  disengages  itself  from  beneath  the  splenii, 
in  order  to  ramify  under  the  skin  of  the  cranium. 

(c)  The  Complexi*  which  form  a  third  stratum,  lying  ob- 
liquely upon  the  subjacent  layer.  The  minor  complexus  is  ex- 
ternal, and  both  are  covered  from  below  upwards  by  the  rhom- 

*  The  French  anatomists  describe  two  complexi  muscles,  the  major  and  minor , 
the  former  M.  Chaussier  denominates  trac&  do-occipital ;  the  latter,  trachtlo-mastm- 
ff'in. — Transl. 


200  OF    THE    NECK. 

boideus,  the  serratus  posticus  superior,  the  splenii  and  trapezius. 
It  is  between  them  that  the  cervical  ligament  is  situated.  They 
are,  moreover,  composed  of  a  great  number  of  bundles,  which 
are  imbricated  as  they  ascend  from  the  transverse  processes  to- 
wards the  median  line ;  they  cross  the  root  of  the  splenii  very 
obliquely,  then  pass  over  the  transversalis  colli,  the  terminations 
of  the  sacro-lumbalis  and  longissimus  dorsi,  over  the  semi-spi- 
nalis  colli,  and  above  the  dentatus,  over  the  obliqui  et  recti  cap- 
itis  postici. 

Between  these  different  muscular  strata,  we  find  nerves,  ves- 
sels and  cellular  lamellae.  Between  the  trapezius  arid  the  second 
layer,  the  cellular  tissue  is  dense,  filamentous  and  very  com- 
pact, superiorly ;  in  the  middle  of  the  region  it  is  lamellatcd,  but 
still  possesses  considerable  compactness;  at  its  most  inferior 
portion,  it  is  much  looser,  and  contains  numerous  adipose  cells 
externally.  Between  the  splenii  and  complexi  the  cellular  tissue 
is  sparing  in  quantity,  except  at  the  superior  part,  where  it  forms 
a  layer  of  considerable  thickness.  Between  the  complexi  and  the 
muscles  beneath  them,  it  forms  thin  lamellae  in  the  two  inferior 
thirds  of  the  region ;  but  in  the  superior  third  this  element  exists 
in  great  abundance,  in  the  first  place  upon  the  median  line  be- 
tween the  complexi,  then  laterally,  between  the  latter  muscles 
and  those  which  we  are  now  about  to  examine. 

The  muscles  which  do  not  extend  throughout  the  whole 
breadth  of  the  posterior  cervical  region  may  be  divided  into  two 
sets :  those  which  lie  above  the  axis,  and  those  which  are  situ- 
ated below  it.  The  latter  form  a  mass  of  greater  or  less  bulk  in 
different  subjects,  which  completely  fills  the  cervical  gutters,  and 
which  is  composed,  in  proceeding  from  the  sides  towards  the  me- 
dian line,  of  the  sacro-lumbalis,  transversalis  colli,  longissimus 
dorsi  and  semi- spinalis  colli;  in  a  word,  we  find  the  prolonga- 
tions of  the  different  bundles  which  enter  into  the  composition  of 
the  sacro-spinalis.  They  present  nothing  very  remarkable  in  a 
surgical  point  of  view. 
The  others  are, 

(a)  The  rectus  capitis poslic,m  major.  This  extends  from  the 
spinous  process  of  the  second  vertebra  to  the  inferior  curved  line 
of  the  os  occipitis,  external  to  the  crest  of  this  bone,  and  is  sepa- 
rated from  its  fellow  by  a  very  narrow  triangular  space,  filled 


OF    THE    NECK. 


with  a  yellowish  and  dense  cellular  tissue  :  it  is  also  separated 
from  the  great  complexus  by  a  very  thick  layer  of  similar  tex- 
ture, in  which  some  nerves  and  vessels  ramify.  Externally,  it  is 
free  and  forms  the  internal  side  of  a  triangle  which  we  will  ex- 
amine directly. 

(  b  )  The  rectus  capitis  posticus  minor  passes  from  the  tubercle 
of  the  atlas  only  towards  the  fossette  which  exists  behind  the 
foramen  magnum,  by  the  side  of  the  median  crest  of  the  os  occi- 
pitis.  It  is  covered  by  the  preceding,  merely  a  thin  lamina  of 
cellular  tissue  being  placed  between  them.  It  lies  directly  upon 
the  occipito-atloidal  ligament. 

(  c  )  The  obliqui  are  so  arranged  that  the  inferior  passes  from 
the  spine  of  the  axis  to  the  transverse  process  of  the  atlas,  and 
the  superior,  from  the  latter  tubercle  to  the  os  occipitis,  between 
the  two  curved  lines,  near  the  termination  of  the  rectus  major  : 
so  that  they  form  a  very  regular  triangle,  in  which  we  observe 
several  important  organs,  such  as  the  vertebral  artery,  the  sub- 
occipital  nerve,  and  a  portion  of  the  ligaments  which  unite  the 
first  two  vertebrae  to  each  other,  as  well  as  to  the  occipital  bone. 
This  space  is  covered  by  the  great  complexus,  and  filled  with  a 
fibro-cellular  tissue,  which  adheres  very  firmly  to  the  muscles, 
vessels,  and  nervous  branches,  and  is  united  particularly  to  the 
periosteum  and  ligaments.  The  obliquus  superior  is  concealed 
by  the  complexi,  and  rests  upon  the  posterior  inferior  part  of  the 
os  occipitis,  between  the  splenius  capitis,  the  great  complexus, 
which  are  above,  and  the  rectus  capitis  posticus  major,  which  is 
below  ;  finally,  it  lies  upon  the  thinnest  part  of  the  inferior  occi- 
pital protuberance  ;  so  that,  if  we  should  apply  the  trepan  below 
the  superior  curved  line,  this  small  muscle  would  necessarily  be 
divided.  The  inferior  oblique  is  also  covered  by  the  complexi, 
and  rests  upon  the  two  vertebrae  to  which  it  is  attached,  upon 
the  posterior  branch  of  the  second  cervical  nerves,  partially  upon 
the  vertebral  artery,  and  upon  some  cellular  tissue. 

This  region  also  contains  two  orders  of  small  muscles  :  these 
are  the  inter-spinales  and  inter-transversales.  The  former  are 
situated  between  the  spinous  processes,  from  the  second  vertebra 
to  the  seventh  ;  between  the  atlas  and  dentatus  (axis),  between 
the  os  occipitis  and  atlas,  the  posterior  recti  appear  to  be  substi- 
tuted for  them.  They  are  double  and  symmetrical,  and  seem  to 


208  OF   THE    NECK. 

us  to  give  support  to  an  opinion  which  we  might  defend  here,  if 
the  nature  of  this  work  permitted  it ;  viz.  that  the  yellow  elastic 
fibrous  tissue  is  susceptible  of  being  converted  into  muscular 
tissue,  according  to  the  necessities  of  the  organs  between  which 
it  is  situated. 

The  latter  (inter-lransversales)  are  arranged  nearly  in  the  same 
manner  between  the  transverse  processes,  from  the  first  cervical 
vertebra  to  the  last.  Between  the  first  and  the  head,  the  rectus 
capitis  literalis  supplies  the  place  of  the  inter-transversalis.  They 
are  double  likewise,  and  each  circumscribe  a  small  triangle 
through  which  the  cervical  nerves  pass,  but  in  such  a  manner, 
however,  that  these  nerves  cannot  be  compressed  by  the  mus- 
cular contractions.  Finally,  they  are  there  confounded  with  the  in- 
sertion of  a  great  number  of  other  muscles ;  which  are,  posteriorly, 
the  sacro-lumbalis,  splenii,  complexi,  transversalis  colli,  longissi- 
mus  dorsi,  semi-spinalis  colli,  and  more  superiorly  the  obliqui ; 
anteriorly,  the  scaleni,  angularis  scapulae,  longus  colli,  and  the 
rectus  capitis  anticus  major. 

v.  The  Arteries. 

All  the  arteries  of  this  region  come  from  the  anterior  part  of 
the  neck,  and  are,  1st.  the  horizontal  branch  of  the  transverse 
cervical,  which  ramifies  principally  between  the  first  two  muscular 
strata ;  2d.  the  cervicalis  profunda,  which,  in  coming  out  from 
the  space  which  exists  between  the  two  last  cervical  vertebra?, 
distributes  twigs  to  the  fasciculi  of  the  vertebral  gutters,  then 
passes  bet\veen  this  mass  and  the  complexi,  and  terminates  in 
the  latter;  3d.  The  ascending  cervical,  which  also  gives  off 
branches  to  the  same  parts,  but  exists  in  the  superior  half  of  the 
region  only ;  4th.  the  occipital,  which  is  the  most  important,  and 
requires  attention.  It  originates  from  the  external  carotid, 
passes  deep  under  the  insertion  of  the  sterno-mastoid  muscle, 
between  the  axis  and  atlas,  then  under  the  splenius  capitis,  and 
enters  the  region  under  consideration  ;  it  next  ascends  in  a  tor- 
tuous manner  upon  the  external  surface  of  the  great  complexus, 
covered  by  the  splenius,  then  by  the  trapezius,  which  it  soon 
perforates  in  order  to  ramify  in  the  subcutaneous  layer.  Some- 
times it  divides  into  two  branches  while  it  is  yet  under  the  mas- 


OP   THE    NECK.  209 

toid  process,  in  which  case  it  would  be  almost  impossible  to  apply  a 
ligature  around  it ;  in  other  cases,  however,  this  division  takes 
place  under  the  trapezius :  then,  if  disease  or  accident  renders 
the  application  of  a  ligature  necessary,  it  might  be  discovered  by 
dividing  the  skin,  subcutaneous  cellular  tissue,  aponeurosis  ,and  by 
separating  the  trapezius  from  the  splenius,  from  the  transverse 
ridge  of  the  os  occipitis  to  the  extent  of  two  inches  downwards. 
From  this  disposition,  we  perceive  that  a  wound  in  the  upper 
part  of  the  neck  might  be  followed  by  considerable  haemorrhage, 
whilst  inferiorly  there  is  no  artery  of  sufficient  volume  to  ex- 
cite any  apprehensions  of  this  nature ;  5th.  the  vertebral  artery 
is  sheltered  from  external  violence,  as  far  as  the  second  vertebra, 
by  its  passing  through  the  canal  in  the  transverse  processes ;  but 
in  coming  out  from  the  third,  it  forms  an  arch  with  a  posterior 
and  external  convexity,  which  is  liable  to  be  wounded  by  instru- 
ments penetrating  to  the  spinal  column.  In  the  transverse  process 
of  the  atlas,  the  vertebral  artery  curves  forwards  and  outwards, 
and  is  again  protected  from  external  violence  :  as  it  issues  from 
this  vertebra  in  order  to  enter  the  cranium  through  the  foramen 
magnum  occipitale,  it  turns  behind  the  condyle  of  this  bone,  upon 
the  posterior  surface  of  the  posterior  occipito-atloidal  ligament, 
which  it  perforates,  or  rather  derives  from  it  a  fibrous  process, 
which  is  converted  into  a  ring  by  the  basilary  process  of  the  os 
occipitis.  It  is  here  especially  that  the  vertebral  artery  forms  a 
very  distinct  curve,  which  is  convex  posteriorly,  and  that  it  is 
exposed  for  some  time  in  the  triangle  heretofore  noticed,  when 
speaking  of  the  oblique  muscle.  It  is  in  this  situation  that  it  is 
most  liable  to  be  wounded.  Previous  to  its  entrance  into  the 
cranium,  it  gives  off  some  small  unimportant  branches. 

vi.  The  Veins. 

They  for  the  most  part  accompany  the  arteries,  and  empty  into 
the  internal  jugular.  There  are  some  which  are  situated  in  the 
cellular  layer  beneath  the  skin,  and  terminate  in  the  external 
jugular.  The  former  also  receive  some  emissary  veins  of  Santo- 
rim,  but  they  are  so  irregular  and  deep-seated,  that  they  afford  no 
special  indication  in  relation  to  venesection. 

37 


OF   THE    NECK. 


vii.  The  Lymphatics. 

Those  of  the  superficial  layer  pass  to  the  superficial  cervical 
glands;  the  greater  portion  of  the  deep-seated,  to  the  deep-seated 
glands  of  the  neck ;  the  remainder  to  those  of  the  axilla.  From 
these  terminations  of  the  lymphatics  we  may  account  for  the 
tumefaction  of  the  axillary  glands  and  those  of  the  infra-hyoidean 
region,  in  consequence  of  diseased  affections  of  the  posterior 
part  of  the  head  and  neck. 

We  have  occasionally  met  with  two  or  three  lymphatic  glands 
upon  the  splenius,  between  the  trapezius  and  sterno-mastoid, 
covered  by  the  skin  and  cellular  tissue,  about  one  inch  below  the 
transverse  ridge  of  the  os  occipitis.  These  glands  sometimes 
become  enlarged,  and  we  should  therefore  recollect  their  seat  in 
order  that  we  may  avoid  mistaking  such  enlargements  for  tumours 
of  a  different  nature. 

vin.  The  Nerves. 

These  are  principally  derived  from  the  posterior  branches  of 
the  cervical  nerves ;  some  from  the  cervical  plexus,  and  the  sub- 
occipital  is  chiefly  distributed  to  this  region.  The  former  are 
situated,  in  the  first  place,  between  the  splenius  and  complexus 
muscles ;  afterwards  their  branches  separate,  some  of  which  pass 
between  the  complexi  and  the  deep-seated  mass,  the  others  pene- 
trate the  fleshy  strata  wrhich  cover  them,  and  all  send  filaments  to 
the  subcutaneous  cellular  tissue. 

The  second  are  the  spinal  (accessory),  which  ramifies  in  the  tra- 
pezius; some  filaments  from  the  deep  descending  cervical 
branches,  which  pass  into  the  same  muscle,  into  the  levator  sca- 
pulae and  the  fibro  cellular  laminae  which  separate  these  two 
muscles  from  those  which  are  beneath  them.  These  are  dis- 
tributed to  the  inferior  part  of  the  neck  only,  and  seem  to  apper- 
tain chiefly  to  respiration  and  sensibility.  The  preceding  occupy 
the  middle  region,  and  are  principally  lost  in  the  locomotive  or- 
gans. There  are  also  some  other  filaments  from  the  auricular 
and  mastoid  branches  of  the  cervical  plexus,  which  are  enclosed 


OF   THE    NECK. 

\vithin  the  laminae  of  the  aponeurosis,  and  terminate  in  the  cellu- 
lar tissue  which  separates  them  from  the  integuments. 

The  sub-occipital,  which  may  be  considered  as  the  first  cervical 
pair,  is  the  most  important  nerve  in  this  region.  Having  passed 
between  the  cranium  and  altas,  it  enters  immediately  into  the 
triangle  circumscribed  by  the  obliqui  and  the  rectus  capitis  posticus 
major,  enveloped  in  the  cellular  tissue  which  fills  this  space,  and 
to  which  it  is  firmly  adherent :  here  it  divides  into  three  principal 
branches,  one  of  which,  like  the  deep  seated  branches  of  the 
other  cervical  nerves,  descends  under  the  complexus  and  finally 
traverses  it.  The  two  ascending  branches  run  towards  the  os 
occipitis,  pierce  the  muscles  or  their  interstices,  anastomose  with 
the  superior  twigs  of  the  cervical  plexus,  between  the  aponeurosis 
and  the  skin,  and  with  other  filaments  appertaining  to  the  facial 
(portio  dura). 

From  this  disposition  it  follows  that  the  nerves  are  most  numer- 
ous in  the  supra-axoidal  portion  of  the  region ;  and  this  is  doubt- 
less the  reason  wrhy  inflammations  of  this  part  are  attended  with 
such  acute  pain.  If  to  this  we  add  the  compact  texture  of  the 
different  tissues  contained  in  it,  we  will  understand  why  its  inflam- 
mations are  so  liable  to  assume  the  erysipelatous  character ;  why 
this  species  of  inflammation  is  so  readily  developed  in  wounds  of 
this  part ;  why  certain  inflammatory  tumours  sometimes  occasion 
such  excruciating  pain,  and  why  pus,  when  secreted,  is  with  so 
much  difficulty  collected  in  the  form  of  abscess  in  this  portion  of 
the  region. 

ix.  The  Skeleton. 

It  comprises  a  great  part  of  the  os  occipitis  and  the  cervical 
portion  of  the  spine. 

That  portion  of  the  os  occipitis  which  corresponds  to  the  lateral 
sinuses  and  comprises  the  superior  curved  line,  as  well  as  the 
external  protuberance,  was  noticed  when  treating  of  the  occipital 
region,  properly  so  called. 

Upon  the  median  line,  we  observe  the  occipital  crest,  which 
corresponds  to  a  similar  crest  within  the  cranium,  consequently 
to  the  falx  cerebelli,  and  to  the  sinuses  which  this  duplicature  en- 
closes. Into  this  crest  the  ligamentum  nuchse  is  inserted,  and  it 


'  OF    THE    ISECK 

generally  forms  an  eminence  which  is  in  a  direct  ratio  to  the 
muscular  power  of  the  individual.  Laterally,  we  see  the  occipital 
bumps,  which  correspond  to  the  inferior  occipital  fossa3  and  to  the 
posterior  part  of  the  cerebellum.  In  this  situation  the  bone  is 
extremely  thin,  but  it  is  covered  by  a  thick  cushion  of  the  soft 
parts :  nevertheless,  fractures  are  not  infrequent  here,  and  are 
the  more  formidable  on  account  of  the  difficulty  of  detecting 
them.  These  fossae  may  be  perforated  by  tumours  of  the  dura- 
mater,  by  the  pressure  of  the  cerebellum,  thus  forming  hernia 
cerebelli,  two  examples  of  which  have  been  recorded  by  M. 
Prof.  Lallemant  and  M.  Baffos.*  It  is  generally  laid  down  as  a 
rule  that  we  should  not  trephine  below  the  superior  curved  line 
of  the  os  occipitis :  however,  if  the  indication  was  positive,  we 
do  not  think  that  the  operation  would  be  very  difficult  or  more 
dangerous  than  in  other  points  of  the  cranium  ;  only  it  would  be 
necessary  to  apply  the  trephine  upon  the  occipital  bump,  and  not 
upon  the  median  line,  nor  too  near  the  superior  curved  line.  It 
has  also  been  said  that  fungous,  or  rather  cancerous,  tumours  of 
the  dura  mater  should  not  be  removed,  notwithstanding  they  may- 
have  perforated  the  cranium,  and  reasoning,  as  well  as  facts,  seem 
to  give  support  to  this  advice  ;  but  we  think  that  it  should  not  be 
too  much  generalized.  It  is  indeed  possible  that  a  tumour  of  this 
nature  may  have  made  its  way  through  the  bone,  without  having 
extensively  disorganized  the  dura-mater  or  encephalon.  In  such 
a  case,  we  do  not  see  why  its  extirpation  should  not  be  under- 
taken, especially  if  the  progress  of  the  disease  will  necessarily 
occasion  the  death  of  the  patient. 

This  observation  is  strengthened  by  a  fact  which  was  recently- 
presented  to  our  notice ;  the  pathological  specimen  has  been 
deposited  in  the  Museum  de  lafaculte. 

A  woman  died  in  Jany.  1825,  at  the  hospital  of  perfection- 
nement,  with  a  hard  and  immoveable  tumour  situated  at  the  inferior 
and  internal  portion  of  one  of  the  lateral  occipital  protuberances : 
this  tumour,  which  was  a  scirrhus  of  the  dura-mater,  had  per- 
forated the  bone.  It  was  as  large  as  a  common  nut,  and  the 
fibrous  membrane  was  perfectly  sound  at  half  a  line  external  to 
this  morbid  production.  Now,  it  is  evident  that  the  extirpation 

*  M.  Boyer,  Trait e  des  maladies  chirurgicales,  elc.t  tome  V.  page  201. 


OF   THE    NECK 

of  this  cancer  was  possible,  and  that  the  operation  would  have 
afforded  the  same  chances  of  success  as  would  have  attended  a 
similar  removal  upon  other  parts  of  the  body. 

If  it  is  true,  as  M.  Gall  affirms,  that  the  organ  of  physical  love 
resides  in  the  cerebellum,  wounds  of  the  osseous  portion,  at 
present  under  consideration,  would  frequently  be  followed  by 
changes  in  this  propensity.  It  is  from  this  idea  that  the  celebrated 
author  of  the  Cranioscopie  says  that  we  may  be  able  to  ascertain, 
from  the  distance  of  the  mastoid  processes  from  each  other,  and 
the  separation  of  the  lateral  eminences  of  the  os  occipitis  the 
strength  or  weakness  of  the  instinct  of  reproduction  in  different 
individuals. 

The  vertebral  column  presents  several  remarkable  peculiarities 
in  this  region : 

(  a  )  It  is  concave,  and  this  concavity  is  in  a  direct  ratio  to 
the  age. 

(  b  )  The  spinous  processes  are  of  unequal  lengths :  thus  the 
first  vertebra  has  none,  for  which  reason  the  head  may  be  thrown 
backwards  with  greater  facility ;  the  spinous  process  of  the  se- 
cond is  thick  and  very  long ;  that  of  the  third  very  short,  and 
the  following  gradually  increase  to  the  seventh ;  so  that,  from  the 
dentatus  (axis)  to  the  last  cervical  vertebra,  there  is  a  notch  which 
is  mostly  filled  with  soft  parts ;  which  notch  should  induce  us  to 
select  the  middle  of  the  neck  for  the  introduction  of  a  seton. 
These  processes  are  almost  horizontal,  and  consequently  quite 
remote  from  each  other,  a  disposition  which  admits  of  much 
latitude  of  motion. 

(  c  )  The  transverse  processes  are  also  very  short ;  their  length 
gradually  decreases  from  the  seventh  and  from  the  first  towards 
the  third :  the  extent  of  motion  which  the  neck  enjoys  is  a  na- 
tural consequence  of  the  shortness  of  these  processes.  Through 
their  base  passes  the  canal  for  the  transmission  of  the  vertebral 
artery,  which  is  thus  protected  against  the  action  of  foreign 
bodies.  Nevertheless,  we  are  of  opinion  that  a  sabre,  or  other 
cutting  instrument,  struck  against  the  side  of  the  neck  with  a 
certain  force,  might  reach  these  vessels  and  occasion  a  wound 
which  would  be  dangerous,  both  on  account  of  the  difficulty  of 
securing  the  vertebral  artery,  as  was  shewn  in  the  infra-hyoidean 
.  and  of  distinguishing  wrhether  the  carotid  or  vertebral  ha? 


214 


OF   THE    AECK 


been  divided.     The  nerves  pass  out  behind  the  artery,  and  divide 
on  the  external  side  of  it. 

(  d  )  The  facets  of  the  oblique  articulating  processes  approxi- 
mate more  to  the  horizontal  direction  than  in  the  other  regions ; 
nevertheless  they  incline  more  and  more  in  descending  from  the 
inferior  facets  of  the  second  to  the  seventh ;  so  that  their  dis- 
placement is  more  difficult  to  accomplish  in  proportion  as  they 
remove  from  the  axis.  This  displacement,  or  luxation  of  the 
cervical  vertebrae  below  the  dentatus,  admitted  by  some,  but 
denied  by  others,  is  certainly  possible :  we  now  possess  incon- 
testible  examples  of  it.  If  only  one  facet  passes  before  the  other, 
without  lacerating  the  intervertebral  cartilage,  the  luxation  is 
incomplete,  and  may  exist  without  paralysis ;  but  if  the  four  sur- 
faces have  abandoned  each  other  and  the  fibro-cartilage  is  torn, 
the  spinal  marrow  is  compressed,  paralysis  immediately  occurs, 
and  even  death.  It  is  especially  between  the  atlas  and  second 
vertebra  that  the  arrangement  of  these  surfaces  is  worthy  of  at- 
tention. Here  they  are  plane,  horizontal,  or  slightly  inclined 
outwards.  On  the  other  hand,  the  atlas  has  no  plates,  properly 
so  called,  no  spinous  process,  no  body ;  consequently,  no  ligamen- 
turn  flavum  nor  fibro-cartilage.  Hence  it  follows  that  the  move- 
ments naturally  exist  in  all  directions,  that  rotation  may  be  car- 
ried very  far  without  danger ;  but,  should  it  pass  beyond  the 
quarter  of  the  circle,  luxation  will  inevitably  ensue,  because  then 
one  of  the  facets  of  the  atlas  passes  before,  and  the  other  behind 
those  of  the  axis.  We  should  particularly  recollect  the  possi- 
bility of  this  accident  during  the  tractions  which  we  exercise 
upon  the  body  of  the  infant  in  parturition,  when  we  operate  by 
turning.  In  fact,  if,  for  example,  the  face  is  placed  anteriorly 
and  the  accoucheur  endeavours  to  turn  it  towards  the  sacrum ; 
for  this  purpose  he  gives  the  trunk  a  slight  turn  at  each  traction 
which  he  executes  ;  and,  if  he  only  considers  the  form,  it  would 
not  be  very  difficult  to  place  the  back  of  the  foetus  towards  the 
pubes.  But  if  the  head  has  not  followed  the  movements  com- 
municated to  the  trunk,  if  it  has  remained  in  the  position  which  it 
occupied  at  the  commencement  of  the  manoeuvre,  a  luxation  of 
the  first  two  vertebral  will  be  produced,  and  the  death  of  the 
infant  will  precede  its  extraction. 

(  e  )  The  union  of  the  head  with  the  atlas,  and  also  with  the 


OP   THE    NECK.  215 

axis,  deserves  particular  attention.  The  condyles  of  the  os 
occipitis  being  convex,  elongated  and  directed  obliquely  out- 
wards and  backwards,  the  superior  facets  of  the  vertebra  upon 
which  they  rest  being  adapted  to  this  disposition,  an  articulation 
is  the  result  which  admits  only  of  flexion  and  extension ;  but  as 
the  occipito-atloidal  ligaments  are  supple  ^nd  broad,  as  the  pos- 
terior arc  of  the  vertebra  is  thin  and  destitute  of  a  spinous  pro- 
cess, this  double  movement  may  be  carried  pretty  far,  less  so, 
however,  than  we  would  be  induced  to  believe  at  the  first  glance, 
because  the  odontoid  process  and  its  ligaments  prevent  the  atlas 
from  being  carried  forwards.  The  rotary  motion  is  principally 
executed  upon  the  odontoid  process  and  the  articulatory  surfaces 
of  the  (axis)  dentatus.  As  we  examine  these  parts  from  before 
backwards  they  thus  present  themselves :  1st.  the  anterior  arc 
of  the  atlas  and  the  ligament  which  unites  it  to  the  os  occipitis ; 
2d.  the  odontoid  process  and  ligaments ;  3d.  the  transverse  and 
occipito-axoidien  ligaments  ;  4th.  the  dura  mater ;  5th.  the  spinal 
canal  filled  with  the  medulla. 

The  odontoid  process  forms  a  species  of  pivot  around  which 
the  atlas  turns :  attached  to  the  inner  side  of  the  condyles  of  the 
os  occipitis  by  two  short  fibrous  bundles,  it  cannot  press  upon 
the  marrow  without  previously  rupturing  the  transverse  ligament 
of  the  first  vertebra,  unless  it  should  slip  from  under  it,  in  which 
case  the  odontoidal  ligaments  must  necessarily  be  previously 
lacerated.  We  are  of  opinion  that,  in  order  to  produce  this 
effect,  in  either  of  these  ways,  considerable  force  is  required. 
It  nevertheless  appears  that  those  who  have  been  hung  frequently 
died  in  this  manner ;  but  more  frequently  the  ligaments  of  the  o- 
dontoid  (ligamenta  moderatoria)  were  first  broken  and  this  process 
had  afterwards  escaped  from  its  ring  below  the  transverse  liga- 
ment of  the  atlas,  and  entered  the  spinal  canal,  so  as  to  lacerate 
the  medulla,  causing  instantaneous  death :  sometimes  also  the 
transverse  ligament  was  broken  and  death  had  taken  place  in 
the  same  manner. 

In  children,  slighter  efforts  will  produce  the  same  effect.  In 
them,  the  vertical  process  of  the  second  vertebra  is  but  slightly 
developed ;  its  ligaments  are  much  less  unyielding ;  the  ring 
which  encloses  it  is  less  close  ;  the  transverse  ligament  also  pos- 
*esses  a  certain  degree  of  elasticity ;  so  that  this  process  might 


OP    THE    MKJK. 


escape  from  beneath  the  latter  band,  without  lacerating  its  pro 
per  ligaments.  These  are  the  different  peculiarities  of  these 
parts  in  youth,  which  enable  us  to  comprehend  how,  by  raising  a 
child  from  the  ground  by  means  of  the  hands  placed  on  each 
side  of  the  head,  we  might  cause  his  immediate  death,  if  he  should 
make  any  struggles  to  disengage  himself  from  our  grasp.  A  case 
of  this  kind  is  related  by  J.  L.  Petit. 

We  may  also  remark  that  the  first  two  cervical  vertebras  are  so 
articulated,  so  connected  with  each  other  and  with  the  head,  that 
an  instrument  or  weapon  might  easily  be  thrust  into  the  spinal 
canal,  without  dividing  any  but  soft  parts,  and  occasion  instant 
death  by  the  injury  inflicted  upon  the  superior  part  of  the  spinal 
marrow.  Thus  if  a  small  sword  is  thrust  into  thefosseite  of  the 
neck,  it  would  possibly  penetrate  the  occipito-atloidal  (infundi- 
buliforme)  or  atloido-axoidien  ligament,  and  cut  through  the  com- 
mencement of  the  medulla  spinalis.  It  was  in  this  manner  that 
the  man  who  destroyed  the  child  spoken  of  by  J.  L.  Petit,  was 
himself  killed  by  the  father  of  this  child,  if  we  can  give  implicit 
credence  to  the  statement  of  these  two  cases. 

This  disposition  seems  to  be  wrell  known  to  butchers,  since 
they  frequently  strike  down  animals  by  plunging  a  knife  behind 
the  os  occipitis;  also  by  common  people,  who  know  that  if  a 
needle  is  thrust  into  this  region,  death  will  be  the  consequence  ; 
and  malefactors  have  more  than  once  profited  by  this  knowledge, 
in  order  to  perpetrate  the  worst  of  crimes,  upon  young  children 
especially.  If  the  instrument  was  introduced  at  the  anterior 
part  it  would  not  be  attended  with  the  like  danger,  because  the 
odontoid  process  of  the  axis  would  prevent  its  reaching  the  me- 
dulla. 

Below  the  second  vertebra,  wounds  of  this  kind  can  no  longer 
take  place.  All  these  bones,  in  fact,  so  overlap  each  other  as  to 
form  a  complete  canal,  the  parietes  of  which  present  no  open 
space  for  the  transmission  of  foreign  bodies. 

Be  this  as  it  may,  it  is  proper  to  recollect  that  a  wound  of  the 
medulla  between  the  first  vertebra  and  the  os  occipitis,  woi  Id 
leave  untouched  the  roots  of  the  par  vagum,  glosso-pharyngeal, 
and  ninth  pair  ;  but  that  all  the  other  nerves,  the  sub-occipital 
oxcepted.  would  be  thus  separated  from  the  encephalon  between 


OP   THE    THORACIC    EXTREMITIES.  ! 

the  first  two  vertebrae.  Between  the  second  and  third,  a  portion 
of  the  cervical  plexus  would  remain;  between  the  third  and 
fourth  the  whole  of  this  plexus  would  escape,  as  well  as  the  spinal 
accessory,  one  or  two  roots  of  which  only  would  be  destroyed. 
Between  the  fourth  and  fifth,  the  phrenic  nerve  would  be  saved, 
and  the  brachial  plexus  in  part  respected ;  lastly,  moVe  inferiorly, 
paralysis  of  the  superior  extremities  will  not  necessarily  ensue. 

The  head  is  so  balanced  upon  the  summit  of  the  spine  that  it 
represents  a  lever  of  the  first  order,  the  anterior  arm  of  \vhich 
would  be  longer  than  the  posterior.  Hence  it  follows  that  the 
head  is  disposed  to  preponderate  anteriorly,  and  that  the  chin  na- 
turally approximates  the  sternum  during  rest  or  sleep. 

During  parturition,  it  is  this  unequal  length  of  the  moveable 
lever  which  the  head  of  the  child  forms,  that  disposes  this  part 
always  to  advance  first,  when  there  are  no  particular  obstacles  to 
prevent  it.  In  fact,  in  this  case,  the  vertebral  column,  which 
represents  the  power,  bears  more  towards  the  occiput  than  the 
chin ;  consequently,  when  the  lever  is  brought  into  play,  this  is  the 
first  part  that  must  descend.  During  life,  the  anterior  arm  of  the 
lever  sometimes  constitutes  the  power  ;  at  other  times,  it  is  the 
posterior  arm  which  represents  it.  In  both  cases,  there  are  mus- 
cles applied  upon  the  whole  length  of  these  arms,  so  that  they  may 
be  lengthened  or  shortened,  according  to  the  demands  of  nature. 

Considered  transversely,  the  head  again  represents  a  lever  of 
the  first  order ;  but  then  the  point  of  support  is  exactly  in  the  mid- 
dle of  its  length.  On  the  other  hand,  the  lateral  movements  not 
existing  in  one  articulation  solely,  but  being  executed  at  the 
expense  of  the  whole  at  the  same  time,  it  becomes,  in  this  res- 
pect, much  less  interesting  than  the  former. 


CHAPTER  III. 
OF  THE  THORACIC  EXTREMITIES. 

In  the  thoracic  extremities  we  will  examine  successively,  1st. 
the  shoulder ;  SJd.  the  arm  ;  3d.  the  elbow ;  4th.  the  forearm  : 
5th.  the  wrist :  6th.  the  hand. 

28 


OF  THE    TilOUAClC    JUXTHE31ITI128. 


ART.  I.    OF    THE    SHOULDER. 

We  divide  the  shoulder  into  an  anterior,  or  thoraco-humeral 
region ;  and  a  posterior,  or  scapulo-humeral  region. 

Sect.  1.  The  Tlwraco-humeral,  Subclavian,or  Axillary  Region. 

The  axillary,  or  anterior  region  of  the  shoulder,  is  the  most  im- 
portant of  the  superior  extremity.  It  is  bounded,  superiorly,  by 
the  supra-clavicular  region ;  inferiorly,  by  the  free  margin  of  the 
pectoralis  major ;  externally,  by  a  line  which  would  fall  perpendi- 
cularly from  the  apex  of  the  acromion  upon  the  free  extremity  of 
the  thumb,  in  the  direction  of  the  external  border  of  the  limb, 
which  line  we  will  call  acromio-digital ;  and  internally,  by  an- 
other line,  drawn  from  the  clavicle,  one  inch  external  to  the  sterno- 
clavicular  articulation,  in  order  to  terminate  upon  the  anterior  and 
superior  spinous  process  of  the  os  coxal  (ilium),  and  which  we 
will  call  clavi-coxal. 

The  surface  of  this  region  presents,  superiorly  and  externally, 
a  spherical  prominence  which  corresponds  to  the  anterior  part  of 
the  head  of  the  humerus ;  on  the  inner  side  of  this  convexity,  a 
broad  and  superficial  groove  which  corresponds  to  the  hollow  of 
the  axilla,  This  groove,  more  strongly  marked  in  emaciated  indi- 
viduals, increases  in  depth  when  the  arm  is  approximated  to  the 
trunk,  and  presents  several  points  worthy  of  consideration. 
Superiorly,  we  observe  a  triangular  depression,  by  which  we  may 
easily  penetrate  into  the  articulation.  If  we  apply  the  thumb 
upon  this  space,  we  will  feel  that  it  is  limited,  externally,  by  the 
head  of  the  humerus ;  internally,  by  the  coracoid  process,  and 
superiorly,  by  the  clavicle  and  acromion.  It  is  at  this  point  that 
MM.  de  Champesmes  and  Lisfranc  have  proposed  introducing 
the  knife  for  the  purpose  of  amputating  the  arm  at  the  joint. 

Below  this  groove  we  meet  with  the  anterior  margin  of  the 
axilla,  a  species  of  rounded  arch,  with  its  concavity  directed 
downwards,  when  the  arm  is  pendent ;  but  straight  and  tense, 
when  elevated  ;  it  is  of  considerable  thickness  in  corpulent  sub- 
jects ;  very  thin,  and  sometimes  almost  cutting,  in  those  who  arc 
emaciated. 


OF   THE    THORACIC    EXTREMITIES.  '210 

Behind  this  border,  we  find  an  excavation,  which  is  increased  in 
depth  as  the  arm  is  lowered,  and  becomes  more  superficial  in  pro- 
portion as  it  is  raised.  This  excavation  is  triangular,  with  its 
base  resting  upon  the  thorax  ;  it  is  bounded  posteriorly  by  another 
border  similar  to  the  preceding,  which  is  formed  by  the  anterior 
portions  of  the  teres  major  and  latissimus  dorsi  muscles :  this  is 
the  posterior  margin  of  the  axilla.  If  we  pass  the  fingers  into  the 
axilla,  we  may  feel  through  the  skin,  when  the  subject  is  not  very 
fat,  the  lymphatic  glands,  the  head  of  the  humerus,  the  nerves  of 
the  brachial  plexus,  and  sometimes  even  the  pulsations  of  the  hu- 
meral artery. 

CONSTITUENT    PARTS. 

\  i.  The  Skin. 

It  does  not  possess  the  same  characters  throughout  the  whole 
extent  of  the  region.  At  the  anterior  part  of  the  shoulder  it  is 
thick  and  less  extensible  than  before  the  axilla,  where  it  is  gener- 
ally delicate  and  very  supple.  The  fibrous  tissue  which  en- 
ters into  its  composition  is  more  compact  in  the  first  direction  than 
in  the  second,  and  there  also  the  sebaceous  follicles  are  larger 
and  more  numerous.  Inferiorly,  in  the  cavity  of  the  axilla,  it  is 
much  more  delicate  still,  very  extensible,  of  a  browner  colour 
than  elsewhere,  covered  with  hairs  which  never  acquire  a  great 
length,  which  are  more  abundant  in  the  male  than  in  the  female, 
and  are  not  developed  until  after  puberty.  The  skin  in  this  situa- 
tion contains  a  great  number  of  large  follicles,  which  secrete  the 
unctuous  matter  usually  found  in  the  axilla.  This  matter  is  more 
or  less  abundant  in  different  subjects ;  sometimes  it  gives  out  a 
very  strong  odour,  especially  in  persons  of  a  fair  and  ruddy  com- 
plexion. At  other  times,  it  is  so  corrosive  that  it  injures  the 
linen,  and  produces  excoriation  of  the  skin  which  it  is  intended  to 
lubricate. 

ii.  The  Subcutaneous  Layer. 

Fat,  cellular  tissue,  vessels  and  nerves  enter  into  the  composi- 
tion of  this  laver. 


2*20  OF    THE   THORACIC    EXTREMITIES. 

The  adipose  vesicles  are  very  large,  and  may  acquire  a  consid- 
erable developement ;  they  are  more  abundant  in  the  anterior 
than  the  inferior  part  of  the  region,  and  may  form  an  extremely 
thick  cushion.  In  proportion  as  they  become  filled,  they  separate 
the  lamellae  of  the  cellular  tissue,  which  approximate,  on  the  con- 
trary, when  the  cells  become  empty :  whence  it  follows  that  in 
fat  individuals  the  cellular  tissue  appears  scattered,  whilst  in  those 
who  are  thin  it  forms  a  distinct  lamina  of  considerable  strength. 
The  cutaneous  surface  of  this  lamina  is  uneven  and  filamentous : 
it  is  this  which  supports  the  adipose  vesicles ;  the  other  surface 
is  lamellatcd,  smooth,  and  does  not  adhere  very  firmly  to  the 
aponeurosis  ;  the  vessels,  especially  the  veins,  ramify  in  the  sheets 
of  this  deep  surface ;  whence  they  are  scarcely  perceptible  in 
fat  individuals.  In  some  persons,  the  subcutaneous  veins  occa- 
sion vergetures  (stains),  quite  strongly  marked  upon  the  skin.  It 
is  also  in  this  layer  that  the  cephalic  vein  takes  its  course.  In  the 
cavity  of  the  axilla,  the  cellular  tissue  is  blended  with  the  aponeu- 
rosis, and  encloses  several  lymphatic  glands  in  its  areola?. 

in.  The  Aponeurosis. 

We  may  consider  it  as  originating  from  the  arm.  In  fact,  the 
fascia  brachialis,  below  the  pectoralis  major  and  latissimus  dorsi, 
is  distributed  in  the  following  manner :  with  regard  to  the  pecto- 
ralis major,  one  layer  passes  before  it,  and  thus  ascends,  under 
the  form  of  a  simple  cellular  sheet,  upon  its  anterior  surface,  and 
over  that  of  the  deltoid  muscle,  in  order  to  attach  itself  to  the 
clavicle.  This  lamina  also  penetrates  into  the  coraco-clavicular 
triangle,  and  thereby  reaches  the  fibrous  capsule  of  the  articula- 
tion ;  it  adheres  firmly  to  the  muscular  fibres,  and,  as  it  is  thin,  it 
is  not  always  easy  to  separate  it  from  them.  Externally,  it  may 
be  readily  distinguished  from  the  subcutaneous  layer.  It  is  im- 
portant to  make  a  distinction  between  those  abscesses  which  form 
without  this  lamina  and  those  which  are  situated  beneath  it :  the  for- 
mer have  a  constant  tendency  to  point  at  the  surface,  and  are  not 
more  dangerous  than  in  the  extremities  ;  the  latter,  on  the  contrary, 
are  very  liable  to  penetrate  into  the  cavity  of  the  axilla,  if  they  are 
not  there  already,  and  in  this  case  we  know  what  a  variety  of 
accidents  they  may  occasion.  Another  aponeurotic  lamina  glides 


OP   THE    THORACIC    EXTREMITIES.  221 

behind  the  pectoralis  major  muscle,  lines  its  posterior  surface,  is 
thicker  and  stronger  externally  than  internally,  but  soon  becomes 
converted  into  cellular  tissue. 

The  same  disposition  exists  in  relation  to  the  latissimus  dorsi ; 
except  that  the  posterior  sheet  is  the  strongest,  as  we  will  find  in 
the  posterior  region  of  the  shoulder.  The  layer  which  passes 
before  this  muscle  is  also  at  first  of  considerable  strength,  but 
becomes  thinner  as  it  ascends,  so  that  soon  a  simple  lamella  only 
remains  which  goes  to  the  posterior  surface  of  the  pectorales, 
after  having  covered  the  free  surfaces  of  the  subscapularis  and 
serratus  magnus ;  which  is  at  length  interposed  between  all  the 
muscles,  its  different  lamina?  afterwards  uniting  together  at  the 
upper  part  of  the  cavity  of  the  axilla,  so  as  to  form  a  more  com- 
pact aponeurosis  before  the  vessels,  the  brachial  plexus,  and  the 
subclavius  muscle.  The  cellular  tissue,  properly  so  called,  seems 
to  result  from  the  unfolding  of  the  aponeurosis,  as  it  passes  from 
one  margin  of  the  axilla  to  the  other.  It  consists  of  an  assem- 
blage of  plates  and  filaments  which  are  continued  \Yithout  inter- 
ruption as  far  as  the  scapulo-humeral  articulation,  with  which  it 
contracts  the  most  intimate  union.  This  cellular  tissue  is  also 
prolonged  behind  the  clavicle,  into  the  supra-clavicular  region, 
and  likewise  forms  a  communication  between  the  axilla  and  the 
posterior  region  of  the  neck,  by  means  of  the  space  which  exists 
between  the  trapezius,  angularis  and  the  second  muscular  stra- 
tum of  this  region.  By  this  train  we  may  explain  the  reason 
wrhy  the  axillary  region  is,  as  it  were,  the  common  rendezvous  of 
all  the  suppurations  which  take  place  in  the  spaces  just  indi- 
cated. 

iv.  The  Muscles. 

(a)  The  Pectoralis  Major.  This  muscle  is  separated  from 
the  skin  by  the  aponeurosis,  superficial  layer,  some  vessels  and 
nerves:  it  lies  successively,  from  above  downwards,  upon  the 
subclavius  muscle,  from  which  it  is  removed  by  a  fibrous  lamina 
indicated  above,  and  by  a  cellulo-adipose  cushion  of  greater  or 
less  thickness ;  upon  the  subclavian  vein  and  artery,  and  upon 
the  nerves  of  the  brachial  plexus,  from  which  it  is  separated  by 
venous,  arterial  and  nervous  branches  of  considerable  magnitude, 


222  OF   THE   THORACIC    EXTREMITIES. 

and  especially  by  a  very  thick  layer  of  cellular  tissue  ;  upon  the 
pectoralis  minor,  below  which  it  again  rests,  but  in  a  less  direct 
manner,  upon  the  axillary  vessels  and  nerves.  Its  fibres  con- 
verge from  the  clavicle  and  ribs  upon  the  humerus  ;  so  that  it  is 
possible  to  reach  the  vessels  by  simply  separating  the  fleshy  fas- 
ciculi without  dividing  them.  This  advice,  which  was  first  rec- 
ommended by  Prof.  Marjolin,*  and  in  a  vague  manner  by 
several  surgeons,  is  now  generally  adopted  when  it  becomes  ne- 
cessary to  tie  the  axillary  artery.  In  order  to  follow  it,  it  is  suf- 
ficient to  make  an  oblique  division  of  the  skin,  superficial  layer, 
and  aponeurosis  of  the  internal  boundary  of  the  region,  begin- 
ning the  incision  at  the  clavicle  and  extending  it  to  just  below  the 
coracoid  process,  that  is  to  say,  parallel  to  the  direction  of  the 
fleshy  fibres.  This  process  is  undoubtedly  preferable  to  that 
which  consists  in  making  a  semilunar  flap  of  the  integuments 
upon  the  fore  part  of  the  clavicle, f  and  still  more  so  than  that  of 
cutting  across  the  tendon  of  the  pectoralis  major.  J  In  the  latter 
case,  in  fact,  even  admitting  its  success,  we  see  that  the  drawing 
down  of  the  arm  and  full  inspirations  would  be  liable  to  be  great- 
ly impeded.  By  its  insertion  into  the  anterior  lip  of  the  bicipital 
sheath,  the  pectoralis  major  muscle  there  constitutes  a  solid  bar- 
rier which  prevents  the  long  head  of  the  biceps  from  escaping 
before  the  gutter  in  which  it  is  lodged.  There  is  a  groove  of 
greater  or  less  depth,  commencing  from  this  insertion,  which  sep- 
arates it  from  the  deltoid  ;  this  groove,  which  we  might  call  cora- 
co-deltoidal,  is  broader  above  than  below ;  it  is  filled  by  adipose 
cellular  tissue,  the  cephalic  vein,  and  the  descending  branch  of 
the  acromial  artery ;  it  is  also  traversed,  quite  near  the  clavicle, 
by  the  transverse  branch  of  this  artery ;  finally,  the  coracoid  pro- 
cess is  usually  found  deeply  seated  in  its  superior  portion. 

( b  )  The  Pectoralis  Minor.  Extended  from  the  coracoid 
process  upon  the  external  surface  of  the  second,  third,  fourth, 
and  sometimes  fifth  ribs,  it  crosses  almost  at  a  right  angle 
the  posterior  face  of  the  pectoralis  major,  being  separated  from 
it  by  a  cellular-adipose  layer  of  considerable  thickness,  in  which 
some  vessels  of  a  certain  magnitude  are  imbedded.  Its  poste 

*  Diclionnairc  dc  Medicine,  article  Anevrisme,  etc, 
|  Hodgson,  Diseases  of  the  Arteries,  etc. 
J  M.  Roux,  Medicine  Operatoire,  &c. 


OF    THE    THORACIC    EXTREMITIES. 

vior  surface  crosses  the  axillary  vessels  and  nerves  in  such  a  man- 
ner, that  we  may  reach  these  vessels,  both  above  and  below  this 
muscle  without  dividing  it.  Its  superior  margin  forms  the  base  of 
a  very  important  triangle,  which  we  call  clam-pectoral.  The  other 
sides  of  this  space  are  represented  by  the  anterior  part  of  the  clavi- 
cle, on  the  one  hand,  and  by  the  upper  part  of  the  clavi-coxal  line, 
on  the  other.  The  first  of  these  margins  measures,  in  a  subject  of 
the  middle  stature,  the  arm  being  slightly  extended,  five  inches ; 
the  length  of  the  second,  beginning  at  the  internal  border  of  the 
coracoid  process,  three  inches  and  a  half;  and  the  last,  which  ex- 
tends upon  the  third  rib,  three  inches  only.  In  this  space  we 
observe,  from  the  chest  towards  the  arm,  some  lax  cellular  tissue, 
the  axillary  anterior  thoracics  and  cephalic  veins,  the  axillary 
and  acromial  arteries,  the  nerves  of  the  brachial  plexus  and  the 
anterior  thoracic  nerves ;  superiorly,  the  subclavius  muscle.  It 
is  in  -this  triangle  that  the  artery  may  be  most  readily  tied,  and  we 
may  reach  it  by  tracing  the  superior  border  of  the  pectoralis  mi» 
nor.  We  will  recur  to  this  again. 

Below  this  muscle,  the  pectoralis  major  conceals  another  trian- 
gle, which  is  larger  than  the  preceding,  but  its  inferior  side  does 
not,  strictly  speaking,  exist,  since  it  would  be  formed  by  the  ante- 
rior margin  of  the  axilla.  It  would  consequently  extend  from  the 
humerus  to  the  sixth  rib,  and  its  length  would  be  about  five  inch- 
es. Its  external  border  is  formed  by  the  humerus,  and  is  three 
inches  and  a  half  long ;  its  superior  side  is  three  inches,  and  is 
represented  by  the  pectoralis  minor.  We  will  call  it  sub  pec- 
toral. 

In  this  triangle  we  observe  a  great  abundance  of  cellular  tissue, 
and  from  within  outwards,  lymphatic  glands,  the  basilic  and  axil- 
lary veins,  the  axillary  artery  enveloped  by  the  nerves,  a  portion 
of  the  coraco-brachialis  muscle,  the  tendons  of  the  latissimus 
dorsi  and  teres  major,  finally,  a  portion  of  the  biceps.  In  this 
situation  the  vessels  and  nerves  run  nearer  the  arm,  whereas  in 
the  clavi-pectoral  triangle  they  lie  nearer  the  thorax. 

(  c )  The  Deltoid.  A  little  less  than  the  anterior  third  of  this 
muscle  appertains  to  this  region.  It  forms  the  fore  part  of  the 
shoulder  and  the  prominence  noticed  when  speaking  of  the  sur- 
face :  it  there  forms  a  species  of  concavity  in  which  the  anterior 
part  of  the  articulation  is  encased.  It  is  separated  from  the  pec- 


;24  OF    THE    THORACIC    EXTREMITIES. 

toralis  major  by  the  coraco-deltoidal  groove.  Its  fibres  descend 
almost  perpendicularly ;  which  should  be  recollected  when  we 
wish  to  make  deep  incisions  in  this  part  of  the  region.  This  por- 
tion of  the  deltoid  forms  a  triangle,  which,  when  removed,  expos- 
es a  similar  space,  in  which  we  see  the  tendon  of  the  pectoralis 
major,  surmounted  by  a  fibrous  prolongation  which  is  continuous 
with  the  scapulo-humeral  capsule,  and  receives  below  the  brach- 
ial  aponeurosis ;  under  this  tendon,  the  bicipital  sheath,  and  the 
tendon  which  it  encloses ;  anteriorly,  the  anterior  part  of  the  hu- 
merus,  the  twro  branches  of  the  anterior  circumflex  artery  ;  more 
superiorly,  the  two  tubercles  of  the  os  burner!,  and  the  tendons 
which  are  inserted  into  them  ;  still  higher,  another  small  triangle* 
formed  anteriorly  by  the  coraco-acromial  ligament ;  posteriorly 
by  the  external  fourth  of  the  clavicle  and  the  apex  of  the  acromi- 
on ;  internally,  by  the  coraco-deltoidal  line  or  by  the  coracoid  pro- 
cess. It  is  at  this  last  space  that  MM.  Champesmes  and  Lisfranc 
recommend  the  knife  to  be  introduced  in  order  to  amputate  the 
arm  at  the  articulation. 

(  d )  The  Subclavius.  The  superior  face  of  this  muscle  was 
treated  of  in  the  supra-clavicular  region ;  at  present  we  have  to 
examine  its  anterior  portion  only.  It  advances  more  or  less  into 
the  axilla,  according  to  the  degree  of  depression  or  elevation  of 
the  shoulder,  and  is  covered  by  a  fibrous  lamina,  to  which  it  gives 
origin,  or  is  united.  This  lamina,  which  was  noticed  when  speak- 
ing of  the  aponeurosis  and  cellular  tissue,  is  attached  to  the  ante- 
rior part  of  the  clavicle,  to  the  coracoid  process,  is  continuous  with 
the  coraco-humeral  ligament,  and  through  it  to  the  brachial  apon- 
eurosis. It  descends  upon  the  fore  part  of  the  axillary  vein, 
upon  which  it  seems  to  be  counfounded,  and  is  continuous  with 
the  cellular  sheath  of  the  vessel.  It  is  also  prolonged  upon  the 
artery  and  the  nervous  bundle  of  the  brachial  plexus,  but  is  soon 
lost  in  the  cellular  tissue  of  the  axilla.  This  aponeurosis  is  of 
considerable  strength  in  some  individuals,  especially  before  the 
vein,  and  is  one  of  the  laminae  which  perplex  us  most  when  we 
wish  to  isolate  the  axillary  artery  in  order  to  apply  a  ligature 
around  it. 

(  e  )  The  Coraco-Brachialis  and  the  short  portion  of  the  biceps' 
originate  in  common  from  the  coracoid  process  but  soon  sepa- 

*  Coraco-acromien, 


OF   THE    THORACIC    EXTREMITIES.  225 

rate,  so  that  the  biceps  passes  before  the  tendon  of  the  latissimus 
dorsi,  whilst  the  coraco-brachialis  descends  obliquely  backwards 
and  outwards. 

(/)  The  Subscapularis.  The  anterior  surface  of  the  teres 
major  and  of  the  anterior  border  of  the  latissimus  dorsi,  here  form 
the  posterior  paries  of  the  arm-pit.  Between  the  teres  major  and 
subscapularis  there  is  a  space,  which  enlarges  as  it  approximates 
the  humerus.  This  space  is  converted  into  an  aperture  almost 
quadrilateral, which  is  circumscribed  above  by  the  anterior  border 
of  the  scapula  and  the  subscapularis,  by  the  teres  major  below, 
posteriorly  by  the  long  head  of  the  triceps,  and  anteriorly  by  the 
neck  of  the  humerus.  This  opening  is  filled  by  cellular  tissue, 
and  through  it  the  axillary  artery  and  nerves  pass. 

(g)  Lastly,  the  serratus  major  anticus,  which  attaches  the 
shoulder  to  tiie  chest,  and  seems  to  unite  the  spinal  border  of  the 
scapula  to  the  posterior  surface  of  the  pectoralis  major.  It  con- 
ceals the  intercostals,  and  forms  the  internal  paries  of  the  axillary 
cavity. 

It  may  now  be  readily  perceived  that  all  these  muscles  sur- 
round a  triangular  pyramidal  cavity,  the  base  of  which  is  inferior 
and  formed  solely  by  the  aponeurosis  and  skin,  and  its  apex,  fill- 
ed with  cellular  tissue  merely,  situated  in  the  posterior  part  of 
the  supra-clavicular  region.  Its  anterior  paries  comprises  the  pec- 
toralis minor,  the  clam-pectoral  and  sub-pectoral  triangles,  and  is 
formed  principally  by  the  pectoralis  major.  Besides  the  subscap- 
ularis, teres  major  and  latissimus  dorsi,  the  posterior  paries  also 
includes,  in  part,  the  anterior  surface  of  the  coraco-brachialis. 
The  serratus  major  anticus  constitutes  almost  the  whole  of  the 
internal  wall,  which  is  completed  by  the  intercostal  muscles  and 
ribs. 

The  internal  and  posterior  parietes  unite,  forming  an  angle 
somewhat  acute,  upon  the  posterior  margin  of  the  scapula.  As 
this  angle  is  completely  closed,  pus  cannot  infiltrate  from  the  ax- 
illa into  the  dorsal  region  without  perforating  the  serratus  major. 
The  angle  which  results  from  the  union  of  the  internal  and  ante- 
rior parietes  is  still  more  acute  ;  it  is  prolonged  upon  the  anterior 
part  of  the  thorax,  and  affords  but  a  feeble  opposition  to  the  infil- 
tration of  pus  or  other  morbid  fluids  in  this  direction.  The  ex- 
ternal angle  is  truncated  superiorly ;  it  includes  a  portion  of  the 

29 


226  OF   THE    THORACIC    EXTREMITIES. 

coraco-brachialis,  the  humerus  and  the  internal  part  of  the  sca- 
pulo-humeral  articulation.  It  is  the  anatomical  disposition  of 
this  side  which  permits  us  to  compress  the  axillary  artery  in  this 
angle. 

v.  The  Arteries. 

(a)  The  Axillary  is  the  principal  trunk  of  this  region,  and 
gives  origin  to  all  the  branches  contained  in  it  This  artery  is 
the  continuation  of  the  subclavian  ;  it  obtains  the  name  of  axillary 
from  the  clavicle  as  far  as  the  posterior  margin  of  the  axilla,  that 
is  to  say,  of  the  latissimus  dorsi.  Its  direction  is  oblique  from 
above  downwards,  and  from  within  outwards.  It  becomes  small- 
er and  smaller  as  it  descends,  which  is  owing  to  the  branches 
given  off  by  it.  Superiorly,  it  is  situated  nearer  to  the  thorax  ; 
inferiorly,  on  the  contrary,  nearer  to  the  arm  ;  whence  it  follows 
that  wounds  penetrating  the  cavity  of  the  axilla  will  be  less  lia- 
ble to  injure  the  artery  if  they  approximate  the  chest ;  whereas 
if  an  instrument  should  penetrate  the  upper  part  of  this  region, 
from  before  backwards,  the  nearer  it  approximates  the  arm  the 
less  would  be  the  risk  of  wounding  this  vessel. 

The  general  relations  of  the  axillary  artery  are  the  following  : 
internally  and  anteriorly,  are  found  the  vein  and  its  principal 
branches,  some  lymphatic  glands,  and  cellular  tissue,  the  scrratus 
inagnus,  aponeurosis  and  the  skin  ;  externally  and  anteriorly,  the 
nerves,  subscapularis  muscle,  tendon  of  the  latissimus  dorsi,  the 
articulation  and  the  humerus ;  anteriorly,  the  artery  is  covered 
by  the  nerves,  veins,  lymphatic  glands,  fibro-cellular  layers,  the 
subclavius,  pectorales  and  coraco-brachialis  muscles,  and  the  in- 
teguments ;  posteriorly,  we  see  some  nervous  branches,  much 
cellular  tissue,  the  subscapularis,  teres  major  and  latissimus  dorsi 
muscles.  But,  in  order  that  we  may  render  these  relations  sus- 
ceptible of  practical  applications,  we  will  adopt  Dr.  Harrison's 
plan  of  dividing  the  axillary  artery  into  three  portions.* 

( b  )  In  the  first  portion,  which  extends  to  the  superior  margin 
of  the  pectoralis  minor,  the  great  axillary  vein  is  on  the  inner 
side  of  the  artery,  and  upon  a  plane  which  is  anterior  to  it :  so 

*  Surgical  Anatomy  of  the  arteries,  Vol.  I.  page  157. 


OF    THE    THORACIC    EXTREMITIES.  227 

that  it  usually  covers  it  so  much,  upon  the  living  subject,  that  it  is 
indispensable  to  draw  it  still  more  internally  when  we  wish  to  tie 
this  artery.  Behind  the  vein,  the  axillary  artery  rests  in  the  first 
place  upon  the  first  intercostal  muscle,  the  second  rib,  and  after- 
wards upon  the  cellular  tissue  which  covers  the  first  portion  of 
the  serratus  major  anticus. 

On  its  acromial  side  runs  the  inferior  branch  of  the  brachial 
plexus,  which  inclines  more  and  more  before  it.  All  the  other 
nerves  remain  more  posteriorly  and  external  to  it.  Still  more 
externally  we  observe  the  cellular  tissue  of  the  summit  of  the 
axilla,  then  the  coracoid  vault. 

Posteriorly,  it  rests,  as  it  comes  out  from  the  supra-clavicular 
region,  upon  the  first  rib,  a  little  upon  the  second,  after  which  its 
its  posterior  surface  is  free  in  the  cellular  tissue  and  is  situated 
before  the  nerves. 

Finally,  considered  anteriorly,  this  portion  of  the  axillary  is 
included  between  the  vein  of  this  name  and  the  nervous  cord 
resulting  from  the  union  of  the  first  dorsal  with  the  seventh  cer- 
vical, so  that  at  its  most  inferior  part  it  is  concealed  by  these  two 
organs,  whereas  we  sometimes  see  it  pretty  distinctly,  in  its 
superior  portion,  without  separating  them.  The  subclavius  mus- 
cle, in  crossing  it,  descends  upon  it  for  about  the  space  of  half  an 
inch  below  the  clavicle.  A  little  lower,  it  is  usually  surmounted 
very  obliquely  by  an  anterior  thoracic  nerve  which  passes  between 
the  two  pectorales,  and  which  might  easily  be  wounded  or  com- 
prised in  the  thread  which  we  place  upon  the  artery.  Anterior 
to  these  parts  there  are  some  dense  cellular  laminae,  and  especial- 
ly the  fibrous  sheet  which  passes  from  the  coracoid  process  to 
the  clavicle  and  upon  the  cartilage  of  the  first  rib,  a  sheet  which 
we  will  call  the  coraco-clavicular  aponeurosis.  This  lamina, 
which,  as  we  have  already  noticed,  is  continuous  with  the  apo- 
neurosis of  the  arm  by  means  of  the  cellular  tissue  of  the  axillary 
cavity,  sometimes  presents  upon  the  fore  part  of  the  vessels  a 
kind  of  semilunar  border,  the  concavity  of  which  looks  down- 
wards and  inwards.  Next  to  this  fibrous  sheet,  the  axillary  artery 
is  separated  from  the  skin  by  an  adipo-cellular  layer  of  more  or 
less  thickness,  by  the  pectoralis  major,  the  aponeurosis  which 
covers  it,  and  the  subcutaneous  texture.  It  here  divides  the 
dam-pectoral  triangle  into  two  nearly  equal  parts,  and  its  direction 


''  OF    THE    TIIOKACR     LXTKE3HTIES. 

follows  that  of  the  coraco-deltoidal  groove,  so  that  by  cutting  upon 
this  groove  we  fall  upon  the  artery,  or  on  the  outer  side  of  it. 

In  order  to  tie  this  vessel  in  the  space  jusr  mentioned,  the  inci- 
sion, which  was  directed  when  speaking  of  the  pectoralis  major 
muscle,  being  made,  and  the  limb  being  approximated  to  the  trunk, 
in  order  to  relax  the  fleshy  fibres,  wre  should  separate  the  lips  of  the 
wound.  Then  the  cellulo-adipose  layer,  enclosing  several  arterial, 
venous  and  nervous  branches,  presents  itself;  which  should  be 
divided  with  the  greatest  caution.  This  layer  being  laid  open, 
we  see  the  superior  margin  of  the  pectoralis  minor,  which  may 
easily  be  drawn  down ;  afterwards  the  prolongation  of  the  coraco- 
clavicular  aponeurosis  is  met  with,  which,  if  cellular  merely,  may 
be  torn  with  the  grooved  director,  but,  if  stronger,  we  should  first 
pierce  it  with  the  bistoury  and  afterwards  enlarge  it  upon  the 
director.  This  being  done,  all  that  is  required  is  to  isolate  the 
artery  and  pass  the  thread  around  it.  In  order  to  accomplish 
this,  we  must  tear  the  species  of  sheath  which  envelopes  the 
bundle  of  axillary  vessels  and  nerves.  As  the  artery  is  situated 
between  and  behind  the  vein  and  the  first  nerve  which  we  see  in 
this  space  in  proceeding  from  the  thorax  towards  the  shoulder, 
we  will  always  seize  it  without  great  difficulty,  if  we  take  the 
precaution  to  enter  the  aneurismal  needle  upon  the  external  side 
of  the  vein,  and  pusli  this  vessel  towards  the  internal  side  of  the 
region. 

The  ligature  should  not  be  placed  too  near  the  subclavius 
muscle,  on  account  of  the  thoracic  nerve  and  cephalic  vein  which 
cross  the  artery  at  this  point ;  neither  should  it  be  applied  too  near 
the  pectoralis  minor,  because  there  we  generally  find  the  origin 
of  the  acromial  and  anterior  thoracic  arteries,  etc. 

( c )  The  second  portion  of  the  axillary  artery  is  concealed 
by  the  pectoralis  minor ;  the  nerves,  all  of  which  were  situated 
at  its  external,  anterior  and  posterior  sides,  send  before  and  behind 
two  cords  which  cross  it  very  obliquely,  in  order  to  reunite  upon 
its  internal  part,  where  they  form  the  median.  In  this  manner 
the  axillary  plexus  constitutes  a  kind  of  sheath  for  the  artery,  and 
the  vein  is  no  longer  in  immediate  contact  with  it;  and  it  is 
besides  more  approximated  to  the  arm  than  the  chest.  Anteriorly 
and  externally  it  corresponds  to  the  biceps  and  pectorales ;  poste- 
teriorly«  to  the  subscapularis.  and  internally,  but  remotely,  to  the 


OP    THE    THORACIC    EXTREMITIES.  *' 

serratus  major.  We  should  never  attempt  to  apply  a  ligature 
upon  this  portion  of  the  vessel ;  the  relations  which  have  just 
been  pointed  out  are  sufficient  to  shew  us  the  dangers  which 
would  result  from  such  an  operation.  If  we  wished  to  compress 
it  here,  the  pressure  should  be  directed  against  the  head  of  the 
humerus ;  but  this  will  scarcely  be  possible  except  in  thin  sub- 
jects ;  and  if  it  was  absolutely  necessary  to  suspend  the  circulation 
in  the  limb,  it  would  be  better  to  establish  the  compression  behind 
the  clavicle ;  we  might  also  apply  the  compressive  means  ante- 
rior to  this  bone,  through  the  pectoralis  major  muscle,  upon  the 
second  rib.  The  latter  method,  however,  is  difficult  and  uncer- 
tain. 

(  d  )  Lastly,  the  third  portion  is  seen  in  the  subpectoral  trian- 
gle. In  passing  through  this  space,  the  artery  has,  upon  its  radial 
side,  one  root  of  the  median,  and  the  musculo-cutaneus  (perforans 
Casserii) ;  upon  its  cubital  side,  are  seen  the  posterior  root  of  the 
median,  the  internal  cutaneus  and  the  ulnar;  externally  and 
posteriorly  the  radial  and  the  axillary  or  circumflex.  The  axillary 
vein  bears  the  same  relations  to  the  artery  here  as  it  does  to  its 
middle  portion,  which  is  covered  by  the  pectoralis  major.  This 
vessel  rests,  posteriorly,  upon  the  tendon  of  the  subscapularis  and 
and  latissimus  dorsi ;  externally,  it  is  applied  against  the  humerus, 
where  we  may  compress  it  pretty  readily.  The  aponeurosis, 
cellular  tissue  and  integuments  ascend  so  as  to  cover  this  artery, 
internally,  in  emaciated  persons.  In  this  third  of  its  length,  the 
axillary  artery  may  be  tied  in  two  different  manners ;  in  the  first 
place,  by  making  an  incision  parallel  to  its  direction,  between  the 
two  borders  of  the  arm-pit ;  and  in  the  second,  by  cutting  upon 
the  fore  part  of  the  pectoralis  major,  perpendicular  to  the  direction 
of  this  muscle,  which  should  be  cut  across  in  order  to  expose  this 
artery.  In  either  case,  we  must  expect  to  find  a  sheath  of  con- 
siderable strength,  which  envelopes,  at  the  same  time,  the  artery, 
vein  and  nerves.  This  sheath  being  laid  open,  it  is  very  easy  to 
separate  these  different  organs  from  one  another,  and  pass  a 
thread  around  the  vessel. 

The  branches  given  off  from  the  axillary  artery  are :  the  aero- 
mial,  anterior  thoracics,  external  mammary  (thnracica  lon^ior). 
the  subscapularis  and  circumflex!. 


230  OF  THE  THORACIC  EXTREMITIES. 

(  a )  The  acromial  This  branch,  in  some  subjects,  separate? 
from  the  trunk  pretty  near  the  subclavius  muscle,  but  more  fre- 
quently immediately  above  the  pectoralis  minor ;  for  which  rea- 
son it  is  generally  preferable  to  apply  the  ligature  nearer  the 
clavicle.  Sometimes  this  branch  gives  off  the  anterior  thoracics ; 
in  which  case  it  is  much  larger  at  its  origin.  The  acromial 
portion  then  passes  directly  before  the  pectoralis  minor,  in  order 
to  bifurcate  behind  the  cephalic  vein,  under  the  apex  of  the  cora- 
coid  process:  one  of  the  branches  of  this  bifurcation  passes  upon 
the  dorsal  surface  of  the  osseous  eminence,  and  goes  to  lose  it- 
self in  the  deltoid.  This  branch,  which  is  sometimes  as  large  as 
a  crow  quill,  is  necessarily  divided  in  the  amputation  of  the  arm 
at  the  joint,  according  to  the  method  of  MM.  Champesmes  and 
Lisfranc. 

The  other  branch  runs  in  the  coraco-deltoid  groove,  is  at  first 
on  the  inner  side  of  the  cephalic  vein,  afterwards  passes  under 
it,  then  on  its  external  side,  and  finally  anterior  to  it :  which  must 
be  borne  in  mind,  if  we  should  fix  upon  this  place  for  vene- 
section. 

(b)  The  anterior  thoracics  originate,  the  superior,  in  the  clam- 
pectoral  triangle,  and  sometimes  even  from  the  acromial ;  the 
inferior,  from  the  middle  portion  of  the  axillary,  under  the  pec- 
toralis minor  muscle ;  their  branches  are  chiefly  distributed  to 
the  pectorales  muscles,  and  intersect  each  other,  in  divers  man- 
ners, in  the  cellular  layers  which  separate  them ;  so  that  they  are 
frequently  much  in  the  way  in  the  ligature  of  the  axillary  artery. 

( c )  The  Mammaria  externa  originates  opposite  to  the  infe- 
rior margin  of  the  pectoralis  minor  and  descends  upon  the  side 
of  the  thorax,  between  the  serratus  anticus  and  pectoralis  major, 
to  lose  itself  in  the  integuments.     It  is  this  which  we  open  most 
frequently  when  we  are  seeking  for  some  tumour  in  the  axillary 
cavity,  as  scirrhous  glands,  for  example,  which  are  generally  situ- 
ted  more  anteriorly  than  posteriorly.     It  also  gives  off  some  other 
branches  externally,  which  ramify  in  the  latissimus  dorsi  and 
teres  major. 

(  d  )  The  Scapularis  Communis,  or  Subscapularis,  is  found  on  a 
level  with  the  anterior  margin  of  the  subscapularis  muscle :  it 
descends  behind  the  nerves  before  the  costa  of  the  scapula,  and 


OF   THE    THORACIC    EXTREMITIES.  231 

soon  bifurcates.  It  is  the  largest  branch  given  off  by  the  axillary, 
and  for  this  reason,  we  should  tie  the  latter  artery  above  or  con- 
siderably below  it. 

The  anterior  branch  of  the  subscapularis,  smaller  than  the 
posterior,  continues  the  primitive  direction  of  the  trunk,  and  rami- 
fies in  the  muscles  of  the  posterior  border  of  the  region ;  the 
posterior,  or  dorsalis  scapulw,  curves  over  the  anterior  margin 
of  this  bone,  in  order  to  pass  into  the  posterior  region  of  the 
shoulder,  where  we  w^ill  see  it  again,  as  well  as  the  preceding. 

( e )  The  Arteries  Circumflexes  frequently  arise  by  a  single  trunk, 
very  near  the  subscapularis,  from  which  they  are  sometimes 
derived.  In  either  case,  the  posterior  circumflex  artery  passes 
immediately  behind  the  shoulder,  through  the  quadrangular  open- 
ing which  the  posterior  paries  of  the  axilla  presents,  under  the 
head  of  the  hurnerus. 

Trie  anterior,  smaller  than  the  other,  is  situated  behind  the 
musculo-cutaneus  nerve,  the  coraco-brachialis,  biceps  and  deltoid 
muscles.  It  is  applied  upon  the  bone,  and  divides  at  the  bicipital 
groove.  With  the  posterior,  it  forms  an  arterial  circle  around 
the  neck  of  the  humerus,  a  circle  wrhich  may  be  lacerated  in 
fractures  of  this  neck ;  whence  result  those  extensive  ecchymoses 
which  occasionally  manifest  themselves  in  consequence  of  these 
wounds. 

The  origin,  volume,  number,  and  distribution  of  all  these  branch- 
es, are  susceptible  of  infinite  varieties.  The  trunk  of  the  axillary 
also  presents  many  anomalies.  We  have  sometimes  seen  it 
divided  into  two  branches,  and,  in  this  case,  one  of  the  branches 
is  posterior,  larger,  and  gives  off  the  brachial,  properly  so  called  : 
the  other  is  anterior,  smaller,  and  seems  to  be  formed  by  the  radial 
prolonged  as  far  as  the  axilla.  We  have  seen  this  division  con- 
tinued even  under  the  subclavius  muscle. 

vi.   The  Veins. 

The  Axillaxy  Vein,  may  be  divided  like  the  artery,  into  three 
portions :  its  superior  portion  is  very  large  and  is  situated,  inter- 
nally, upon  the  border  of  the  first  rib,  the  first  intercostal  muscle, 
the  second  rib,  and  the  superior  point  of  the  serratus  major  anti- 
cus ;  externally  and  posteriorly,  upon  the  axillary  artery,  to  which 


4232  OF   THE    THORACIC    EXTREMITIES. 

it  adheres  by  pretty  compact  cellular  lamelae ;  anteriorly,  it  re- 
ceives a  process  from  the  cora co-clavicular  aponeurosis  which 
strengthens  its  external  tunic ;  it  is  afterwards  crossed  by  the  an- 
terior thoracic  nerve  and  arteries,  then  it  is  covered  by  the  cel- 
lulo-adipose  sub-muscular  layer,  etc.  The  dilatation  of  the  veins, 
which  takes  place  during  expiration,  causes  this  portion  of  the 
axillary  vein  to  conceal  the  artery  entirely.  As  this  dilatation  is 
one  of  the  principal  obstacles  to  placing  a  ligature  around  the  ar- 
tery, it  would  perhaps  be  advantageous,  in  performing  this  opera- 
tion, to  adopt  the  plan  proposed  by  Mr.  Lizars,  that  is  to  say,  to 
suspend  the  venous  circulation  below  the  axilla  by  the  compres- 
sion of  the  extremity. 

Behind  the  pectoralis  minor,  the  axillary  vein  is  crossed  by  the 
branches  of  the  inferior  thoracic  artery,  and  it  is  separated  from 
the  internal  surface  of  the  artery  by  the  two  roots  of  the  median 
nerve. 

In  its  inferior  portion,  it  is  still  on  the  inner  side  of  the  artery, 
but  it  is  situated  more  anteriorly,  and  the  median,  internal  cuta- 
neus,  and  ulnar  nerves  separate  these  two  vessels.  Anteriorly  it 
is  crossed  by  the  external  mammary  artery,  the  two  nervous 
branches  which  pass  from  the  second  and  third  intercostals  to  the 
hollow  of  the  axilla,  and  some  other  filaments  ;  consequently,  the 
whole  of  the  brachial  plexus  is  situated  behind  and  external  to  it. 

It  is  generally  in  the  sub-pectoral  triangle  that  it  receives  the 
basilic  vein,  which  sometimes  equals  it  in  size,  and  the  collateral 
veins  of  the  subscapulary,  circumflex,  and,  sometimes,  external 
mammary  arteries.  The  latter  and  the  basilic  empty  into  it  upon 
its  internal  and  anterior  part ;  the  others,  on  the  contrary,  into  its 
external  and  posterior  portion,  and  their  trunks  are  seen  in  the 
interval  of  the  nerves  of  the  brachial  plexus. 

Hence  it  follows  that  the  veins  form  in  this  situation  a  very 
complicated  plexus,  which  produces  much  embarrassment  when 
we  attempt  to  isolate  the  artery. 

In  some  subjects,  these  different  venous  branches  remain  dis- 
tinct even  under  the  pectoralis  minor  ;  but  this  is  rare,  for  gener- 
ally the  external  mammary  and  inferior  thoracic  veins  open  into 
each  other  under  this  muscle.  In  the  superior  third  the  axillary 
receives  an  uncertain  number  of  small  venous  twigs  ;  but 


OF   THE   THORACIC    EXTREMITIES.  233 

uniformly  the  superior  thoracic  and  the  acromial  are  there  emptied 
into  it. 

The  cephalic  vein  also  enters  the  subclavian,  and  from  its  sur- 
gical importance  it  requires  minute  investigation :  it  is  moreover 
the  only  superficial  branch  which  deserves  our  attention  here* 
It  is  lodged  in  the  groove  which  separates  the  deltoid  and  pecto- 
ralis  major,  and  is  more  or  less  deeply  situated  in  proportion  to 
the  degree  of  separation  of  these  two  muscles.  When  the  groove 
is  but  slight,  the  vein  is  very  superficial ;  but  when  it  extends  to 
the  bone,  the  vein  is  deeply  seated.  In  the  middle  of  this  groove 
the  cephalic  vein  is  enveloped  by  cellular  lamellae  and  adipose  vesi- 
cles. In  making  its  way  under  the  clavicle,  it  passes  along  the  inner 
side  of  the  eoracoid  process,  before  the  origin  of  the  biceps  and 
coraco-brachialis  muscles  and  the  insertion  of  the  pectoralis  minor  ; 
it  crosses  the  nerves  of  the  brachial  plexus  and  axillary  artery  ob- 
liquely, and  falls  into  the  vein  upon  its  external  and  anterior  side, 
quite  near  to  the  subclavius  muscle.  In  this  track,  this  vessel 
crosses  the  acromial  artery  in  such  a  manner  that  the  latter 
forms  a  semi-spiral  turn  upon  the  vein,  as  it  is  passing  behind  it. 
From  what  has  preceded,  it  follows  that  the  cephalic  vein  is, 
all  other  things  being  equal,  more  superficial  the  nearer  it  approx- 
imates to  the  deltoidal  groove ;  that  it  is  always  separated  from 
the  skin  by  an  adipose  layer  which  varies  much  in  thickness,  and 
that  an  artery  of  considerable  volume  runs  by  the  side  of  it.  Con- 
sequently, if  we  wished  to  open  it  in  venesection,  it  would  be 
preferable  to  do  it  rather  below  than  high  up.  We  cannot  say 
that  a  similar  operation  would  be  dangerous  ;  but  it  appears  to  us 
so  serious,  that  it  is  doubtful  whether  it  should  be  frequently  per- 
formed when  bleeding  presents  difficulties  at  the  bend  of  the 
elbow. 

VH.  The  Lymphatics. 

They  are  veiy  numerous  in  this  region:  all  the  lymphatics  of 
the  superior  extremity,  those  of  the  exterior  of  the  thorax,  and  a 
part  also  of  those  of  the  posterior  portion  of  the  neck  enter  into 
it.  We  find  in  it  a  considerable  number  of  lymphatic  glands, 
some  of  which  form  a  species  of  chain  around  the  vessels,  whilst 
the  others  are  distributed  into  two  series.  The  one  constitutes 

30 


234  OF    THE    THORACIC    EXTREMITIES. 

an  anterior  plane  situated  between  the  anterior  paries  of  the 
axilla  and  the  vascular  and  nervous  plexus.  The  other,  or  pos- 
terior plane  is  placed  between  the  same  plexus  and  the  posterior 
paries  of  the  axilla.  These  glands  occupy,  still  more  especially, 
the  space  which  separates  the  vessels  and  nerves  from  the  serra- 
tus  magnus,  and  this  circumstance  is  very  advantageous  to  the 
surgeon  ;  for,  when  the  extirpation  of  these  organs  becomes  ne- 
cessary, by  recollecting  this  anatomical  disposition,  we  would  not 
be  so  readily  stopped  by  the  depth  of  their  situation.  There  is 
also  a  very  simple  method  of  ascertaining  whether  it  is  prudent  to 
attempt  their  removal ;  it  consists  in  raising  the  arm  from  the 
trunk :  if,  in  this  position,  the  tumours  remain  applied  upon  the 
thorax,  or,  simply,  if  they  do  not  follow  the  limb  in  its  movements, 
it  is  certain  that  they  have  no  intimate  relation  with  the  vessels 
and  nerves. 

We  know  with  what  facility  these  glands  become  engorged  and 
swollen  in  diseases  of  the  breast  in  females,  of  the  whole  chest  in 
both  sexes,  and  especially  in  those  of  the  superior  extremity. 
This  sympathetic  enlargement  frequently  leads  us  to  detect  an 
affection  in  parts  where  we  would  scarcely  suspect  it.  It  is  in 
virulent  inflammations  and  suppurations  particularly  that  the 
axillary  glands  tumefy  with  great  rapidity  ;  it  is  on  such  occa- 
sions also  that  the  suppuration  sometimes  invades,  with  an  alarm- 
ing celerity,  the  lax  and  abundant  cellular  tissue  which  surrounds 
them :  hence  those  enormous  abscesses  which  are  propagated  so 
speedily  into  the  circumjacent  regions,  through  the  medium  of  the 
cellular  prolongations.  When  swollen,  these  glands  very  fre- 
quently produce  infiltration  of  the  limb  :  is  this  merely  owing  to 
the  obstruction  which  the  lymph  meets  with  in  its  course  to  the 
organs  destined  to  receive  it  ?  Is  it  an  effect  Of  the  compression 
of  the  bloodvessels,  the  veins,  for  example  ?  The  first  cause  ap- 
pears to  us  to  be  the  most  frequent ;  the  second,  however,  is  not 
very  rare. 

It  is  necessary  to  remark,  that  in  the  cavity  of  the  axilla  there- 
is  every  condition  reunited  that  can  favour  the  production  of 
inflammation  within  it,  and  the  rapid  termination  of  this  inflam- 
mation in  an  abundant  purulent  secretion:  thus,  the  vascular 
and  thin  skin,  constantly  sliding  over  the  tissues  which  it  covers; 
a  very  abundant,  supple,  and  extensible  cellular  texture,  filled 


OP   THE    THORACIC    EXTREMITIES.  ,  'J35 

with  vessels ;  nervous  filaments  in  great  numbers  ;  an  almost 
constant  stretching  of  these  parts,  from  the  natural  motions  of 
the  limb,  &c. 

It  is  also  in  consequence  of  these  conditions  that  leeches  ap- 
plied to  the  arm-pit  usually  produce  in  it  extensive  ecchymoses. 

vin.  The  Nerves. 

Almost  all  of  them  are  derived  from  the  brachial  plexus.  The 
greater  part  of  this  plexus  is  found  in  this  region :  in  the  clavi- 
pectwal  triangle  its  cords  are  collected  in  a  bundle  behind  and  on 
the  outer  side  of  the  artery ;  free  under  the  clavicle  and  towards 
the  summit  of  the  axilla,  where  it  lies  upon  the  cellular  tissue,  it 
corresponds,  anteriorly,  to  the  coraco-deltoidal  groove,  and  is  con- 
sequently only  separated  from  the  skin  by  fat,  cellular  texture, 
and  the  transverse  branch  of  the  acromial  artery,  the  cephalic 
vein  lying  more  internally.  It  does  not  follow  from  these  rela- 
tions that  this  plexus  is  not  very  deeply  seated ;  but  they  admit 
of  its  being  reached  without  dividing  the  muscles.  For  ex- 
ample :  a  pointed  instrument,  thrust  perpendicularly  to  the  axis 
of  the  trunk,  upon  the  internal  border  of  the  coracoid  process,  in 
the  retiring  angle  (angle  rentrant)  which  exists  between  the 
clavicle  and  this  eminence,  will  fall  directly  upon  the  nerves,  and 
will  scarcely  expose  the  artery. 

It  is  in  passing  under  the  pectoralis  minor  that  this  plexus  un- 
ravels itself:  it  is  then  that  it  detaches  two  branches  which  pass 
below  and  before  the  axillary  artery  and  place  themselves  be- 
tween this  vessel  and  the  vein  of  the  same  name,  in  order  to 
form  the  median  nerve.  Below  this  muscle,  that  is  to  say,  in  the 
sub-pectoral  space,  all  the  nerves  of  the  arm  are  usually  isolated. 

(  a )  The  Median  Nerve  remains  on  the  inner  side  of  the 
artery,  and  sometimes  is  found  before  it  when  it  enters  into  the 
brachial  region  ;  so  that  if,  we  attempted  to  tie  the  arterial  trunk 
in  this  part  of  the  axilla,  it  would  be  more  easy  to  draw  this  nerve 
backwards,  near  the  pectoralis  minor  muscle ;  and,  on  the  con- 
trary, to  pull  it  forwards,  if  we  operated  near  the  anterior  border 
of  the.  region.  The  vein  or  veins  lie  upon  its  inner  side. 

(  b  )  The  Musculo-Cutaneus,  which  is  continuous  with  the 
anterior  root  of  the  'median,  removes  from  the  vessels  and  gains 


236  OF    THE    THORACit!    EXTREMITli.*, 

the  posterior  surface  of  the  coraco-brachialis  muscle,  which  it 
traverses.  Its  relations  with  the  artery,  therefore,  are  very 
remote. 

(c)  The  Circumflex  separates  from  the  posterior  part  of  the 
plexus,  a  little  higher  than  the  inferior  border  of  the  subscapu- 
laris  muscle,  over  which  it  turns  in  order  to  pass  under  the  cervix 
humeri  through  the  sub-scapulo-humeral  aperture.  The  relations 
of  this  nerve  with  the  bone  are  such,  that,  in  fractures  of  its  neck, 
it  may  be  lacerated  and  occasion  severe  symptoms.  In  luxa- 
tions downwards,  also,  it  is  almost  necessarily  compressed  by  the 
head  of  the  humerus. 

(  d  )  The  radial  or  musculo-spiral  is  detached  on  a  level  with 
the  circumflex,  and  frequently  these  two  cords  form  at  first  only 
a  single  trunk.  Situated  completely  behind  the  plexus,  it  turns, 
as  it  descends,  upon  the  inner  surface  of  the  humerus,  and  enters 
between  the  internal  and  posterior  portions  of  the  triceps.  It 
may  likewise  be  stretched,  or  lacerated,  in  fractures,  and  com- 
pressed in  luxations  inwards.  It  has  no  immediate  relations 
with  the  artery. 

(  e  )  Internally  and  anteriorly,  we  see  the  Internal  Cutaneus, 
which  is  placed  between  the  vein  and  artery,  and  is  sometimes 
so  large  that  some  persons  have  mistaken  it  for  the  median,  when 
seeking  for  the  axillary  artery. 

(/  )  The  Cubital  (Ulnar)  is  more  internal  and  posterior:  it  is 
also  covered  by  the  veins.  Its  volume  is  equal  to  that  of  the 
median,  from  which  we  distinguish  it  by  its  position,  and  because 
in  removing  from  its  origin  it  also  removes  from  the  artery,  in- 
clining backwards. 

Such  is  the  arrangement  of  the  six  brachial  branches  of  the 
axillary  plexus  ;  but  this  plexus  gives  off  in  the  axilla  some  other 
nerves,  which  we  are  now  going  to  point  out :  these  are  the  ante- 
rior thoracic  and  subscapulary  branches. 

(  g  )  The  Thoracic  Nerves  vary  in  number,  but  there  are  two 
in  particular  which  we  shall  mention. 

The  first  originates  from  the  fore -part  of  the  plexus,  in  the 
summit  of  the  clavi-pectoral  space,  and  runs  obliquely  forwards, 
downwards,  and  inwards :  it  gives  several  filaments  to  the  cellulo- 
adipose  layer,  and  terminates  by  a  small  number  of  ramuscules 
in  the  pectoralis  major  muscle.  Near  its  root,  it  passes  over  the 


OF    THE    THORACIC    EXTREMITIES. 

axillary  vessels ;  so  that  it  may  interfere  with  the  ligature  of  the 
artery,  and,  in  order  to  avoid  it,  it  should  be  pushed  upwards  and 
towards  the  sternum.  It  is,  moreover,  between  this  nerve  and 
the  acromial  artery  that  the  thread  should  be  applied  around  the 
axillary  artery.  Near  its  origin  it  is  also  crossed,  in  its  turn,  by 
the  termination  of  the  cephalic  vein. 

The  second  branch  arises  a  little  lower  down  and  runs  behind 
the  artery,  then  between  it  and  the  vein,  in  order  to  pass  under 
the  inferior  margin  of  the  pectoralis  minor,  and  is  lost  in  the 
posterior  surface  of  the  pectoralis  major.  As  it  passes  round  the 
arterial  trunk,  this  nerve  is  sometimes  so  adherent  to  it  that  it  is 
pretty  difficult  to  separate  them.  It  is  of  importance  to  recollect 
this  circumstance  when  about  to  tie  this  vessel. 

(  h  )  The  Subscapulary  nerves  vary  still  more  in  number  than 
the  thoracics.  They  all  pass  backwards  in  the  cellular  tissue, 
and  terminate  in  the  muscle  which  bears  their  name.  They  may 
be  compressed,  like  all  the  others,  in  luxations  inwards,  or  by 
tumours  which  form  in  the  cavity  of  the  axilla. 

(  i  )  Posteriorly  and  internally,  we  observe  the  posterior  tho- 
racic nerve,  which  comes  from  the  supra-clavicular  region.  This 
cord  rests  upon  the  axillary  aspect  of  the  serratus  major  anticus, 
to  which  it  is  distributed.  It  is  important  to  recollect  its  rela- 
tions, in  order  that  we  may  avoid  it  in  operating  in  the  hollow  of 
the  axilla  ;  for,  if  the  function  of  this  nerve  should  be  annihilated, 
it  might  very  seriously  disturb  the  mechanical  phenomena  of 
respiration,  since  it  is  the  only  one  which  is  distributed  to  the 
serratus  magnus.  It  is  for  this  reason  that  Mr.  C.  Bell  has  called 
it  the  inferior  external  respiratory  nerve.  Reasoning  would  lead 
us  to  infer  that  the  posterior  border  of  the  shoulder  would  then 
be  more  prominent  backwards  and  upwards,  and  that  the  scapula 
would  no  longer  be  immediately  applied  upon  the  side  of  the 
thorax.  We  have  seen  a  man  of  twenty-six  years  of  age,  strong 
and  of  a  good  constitution,  who  was  in  this  state  for  six  months. 
He  had  fallen  and  struck  the  cavity  of  the  axilla  against  the 
angle  of  a  bureau.  The  phenomena  which  have  just  been  men- 
tioned appeared  to  us  to  depend  upon  a  paralysis  of  the  serratus 
magnus.  This  young  gentleman  recovered  under  the  repeated 
application  of  blisters  around  the  shoulder  and  thorax. 

(j )  The  Intercostal  Twigs  of  the  axilla,  coming  out  from  the 


238  OF   THE    THORACIC    EXTREMITIES. 

thorax,  are  placed  upon  the  second  and  third  ribs,  before  the 
corresponding  digitations  of  the  serratus  magnus,  and  ramify  in 
the  cellular  tissue,  in  the  lymphatic  glands,  around  the  vena 
basilica  and  in  the  skin.  These  are  the  filaments  most  frequent- 
ly  wounded  in  extirpating  glands  which  have  become  scirrhous 
in  consequence  of  cancer  in  the  breast :  it  is  perhaps  these  nerves 
also  which  occasion  the  sensation  of  anguish,  constriction,  and  the 
distressing  suspirations  with  which  patients  are  afflicted  in  these 
affections. 

ix.  TJie  Skeleton. 

The  Skeleton  of  the  Sub- Clavicular  Region  is  composed  of  the 
anterior  and  internal  half  of  the  head  of  the  humerus,and  of  the  cor- 
responding surfaces  of  this  bone  ;  of  a  part  of  the  clavicle,  and  of 
the  four  ribs  which  follow  the  first ;  of  the  coracoid  process  and  of 
a  part  of  the  acromion,  and  of  the  scapulo-humeral  articulation. 

(  a  )  The  Humerus  here  presents  the  bicipital  groove  which 
receives  upon  its  anterior  labium  the  tendon  of  the  pectoralis 
major,  and  upon  the  posterior,  those  of  the  latissimus  dorsi  and 
teres  major.  It  is  important  to  mark  these  insertions,  both  on 
account  of  fractures  and  luxations.  For,  if  the  fracture  exists 
lower  down,  yet  above  the  insertion  of  the  deltoid,  the  superior 
fragment  will  necessarily  be  drawn  near  the  trunk  by  the  action 
of  these  muscles  :  if,  on  the  contrary,  it  takes  place  above  them, 
the  superior  fragment  will  be  free  on  this  side,  whilst  the  inferior, 
in  its  turn,  will  be  drawn  towards  the  chest.  In  luxations,  if  the 
displacement  occurs  whilst  the  inferior  extremity  of  the  humerus 
is  fixed  upon  the  ground,  during  a  fall,  or  upon  any  solid  body 
whatsoever,  let  the  cause  be  direct  or  indirect,  it  is  evident  that 
the  muscles  just  mentioned  will  act  upon  the  os  brachii  as  on  a 
lever  of  the  third  order.  Hence,  as  the  power  in  this  case  is 
very  near  the  moveable  point,  we  conceive  that  the  head  of  the 
humerus  will  be  drawn  forcibly  inwards. 

The  bicipital  groove  becomes  deeper  and  deeper  as  it  ascends, 
and  when  it  passes  between  the  two  tubercles  of  the  head  of  the 
humerus,  it  is  converted  into  a  complete  canal  by  the  articular 
capsule  ;  this  disposition  is  perfectly  in  relation  with  the  usages 
of  the  biceps  muscle:  by  this  mechanism,  it  is  impossible  for  the 


OF   THE    THORACIC    EXTREMITIES. 

tendon  of  this  muscle  to  escape  from  the  sinus  in  which  it  is 
lodged,  during  the  rotatory  movements  of  the  arm,  and  its  con- 
tractions are  in  no  measure  impeded,  let  the  position  of  the  limb 
be  what  it  may. 

Anterior  to  this  groove,  the  aspect  of  the  humerus  is  rounded ; 
the  deltoid  muscle  covers,  but  does  not  adhere  to  it ;  it  is  sepa- 
rated from  it  by  a  lamellated  cellular  tissue ;  two  thirds  of  the 
greater  tuberosity  (trochiter)  are  placed  under  it,  into  which  the 
tendons  of  the  supra  and  infra-spinati  muscles  are  inserted. 

Posteriorly,  we  observe  the  insertion  of  the  coraco-brachialis 
muscle,  which,  in  fractures  of  the  neck  of  the  bone,  will  act 
upon  the  lower  fragment  in  the  same  direction  as  the  pectoralis 
major  muscle,  etc.,  likewise  tending  to  draw  it  forwards  and 
upwards :  the  lesser  tuberosity  of  the  os  brachii  (trochiri),  upon 
which  the  tendon  of  the  sub-scapularis  muscle  is  fixed,  represents 
tolerably  well  the  powerful  extremity  of  a  lever  of  the  first  order. 
Below  these  tuberosities,  between  them  and  the  body  of  the 
bone,  is  the  surgical  neck.  This  neck  is  smooth  and  round,  and 
does  not  present  any  muscular  impression ;  which  renders  it 
more  susceptible  of  fractures.  These  fractures  are  accompanied 
with  peculiar  dangers,  and  present  special  indications  :  1st.  dan- 
gers,— because  the  circle  which  is  here  formed  by  the  circumflex 
vessels  may  be  lacerated,  and  it  is  doubtless  to  the  laceration  of 
the  vein  in  particular,  that  we  must  attribute  those  extensive 
ecchymoses  which  sometimes  follow  fractures  of  this  nature  ; — 
because  the  nerve  of  the  same  name  may  also  be  stretched,  or 
lacerated  ;  which  might  paralyze  the  deltoid,  in  the  first  place,  and 
afterwards  give  rise  to  very  severe  nervous  symptoms;  and 
finally,  because  the  inferior  fragment,  almost  always  drawn  in- 
wards and  upwards,  may  compress,  stretch  or  tear  the  nerves 
and  vessels  of  the  axilla.  2d. — The  indications  which  present 
themselves  arise,  first,  in  consequence  of  these  accidents,  after- 
wards because  the  apparatus  can  scarcely  act  but  on  the  inferior 
fragment  of  the  bone ;  for  which  reason  the  ordinary  bandages 
for  fractures  of  the  humerus,  in  general,  those  of  Ledran  and 
Desault  for  its  neck,  and  many  others,  are  almost  useless,  whilst 
it  is  sufficient,  in  order  to  accomplish  the  proposed  object,  to 
place  a  pad  of  moderate  thickness  between  the  arm  and  chest, 
and  keep  the  limb  approximated  to  the  trunk  in  any  manner  what- 


240  OF    THE    THORACIC    EXTREMITIES. 

soever;  indeed,  we  might  do  without  the  pad.  We  have  seen 
this  very  simple  means  uniformly  successfully  employed  by  M. 
Richerand  at  the  Hospital  Saint-Louis ;  and  it  may  be  readily 
explained :  in  fact,  all  the  muscles  which  produce  the  displace- 
ment of  the  inferior  fragment  are  relaxed  by  this  position  of  the 
arm ;  this  same  fragment  is  then  pretty  forcibly  drawn  outwards 
by  the  tense  fibres  of  the  deltoid,  which,  on  the  other  hand,  pre- 
vent the  superior  fragment  from  being  carried  outwards  or  for- 
wards. Thus,  the  muscular  action  which  had  displaced  the  parts 
is  the  means  which  we  employ  to  retain  them  in  coaptation,  and 
immobility  alone  is  the  necessary  requisite  for  the  cure. 

We  will  resume  the  consideration  of  the  articulation  in  the 
region  which  follows. 

(  b  )  The  coracoid process  is  separated  from  the  acromion  by  a 
triangular  space  (coraco-acromial),  which  the  point  of  the  knife  tra- 
verses in  the  extirpation  of  the  arm  by  the  process  of  MM.  Cham- 
pesmes  and  Lisfranc,  and  at  which  it  comes  out  when  we  follow 
the  method  peculiar  to  M.  Lisfranc.  We  will  recur  to  this  again. 

Being  crossed  by  the  clavicle,  it  opposes  acromio-clavicular 
luxations.  It  is  on  the  inner  side  of  this  process  that  the  clavicle 
appears  to  be  deepest.  The  beak  of  the  coracoid  process  affords 
attachment  to  the  pectoralis  minor,  biceps  and  coraco-brachialis  ; 
whence  it  follows  that  its  fracture  must  interfere  with  the  inspira- 
tory  movements  of  the  thorax,  those  of  elevation  and  adduction 
of  the  arm,  and  the  depression  of  the  shoulder. 

The  coracoid  process  is  one  of  the  parts  which  most  directly 
oppose  the  luxation  of  the  arm  upwards.  It  is  separated  from  the 
head  of  the  humerus  by  a  space  of  about  an  inch ;  which  space  is 
filled  by  the  coraco-humeral  ligament  and  the  tendon  of  the  supra- 
spinatus  muscle. 

We  will  examine  the  acromion  and  the  corresponding  extremi- 
ty of  the  clavicle  more  particularly  in  the  posterior  region  of  the 
shoulder. 

(c)  The  Clavicle,  the  horizontal  branch  of  the  angular  lever 
which  forms  the  skeleton  of  the  shoulder,  enters  almost  entirely 
into  the  region  of  the  axilla. 

As  this  bone  is  one  of  those  which  first  make  their  appearance 
in  the  foetus,  and  as  its  developement  is  generally  very  rapid,  some 
persons  have  thence  concluded  that  it  enjoyed  a  much  greater  de- 


OP   THE    THORACIC    EXTREMITFES.  241 

gree  of  vitality,  and  have  therefore  attributed  to  this  cause  its 
more  frequent  liability  to  exostosis  and  other  tumours.  To  this 
opinion  we  might  make  a  great  many  objections. 

Its  superior  aspect  is  covered  only  by  the  skin,  the  superficial 
cellular  layer  and  some  fibres  of  the  platysma  ;  so  that  it  may  be 
distinctly  felt  by  passing  the  finger  over  the  surface,  and  it  is  for 
this  reason  that  we  should  choose  this  part  of  the  bone  when  we 
wish  to  discover  its  fractures. 

Anteriorly,  the  clavicle  gives  attachment  to  the  pectoralis  ma- 
jor at  its  internal  half,  and  to  the  deltoid  in  its  external  third.  In 
thin  individuals  the  anterior  part  of  this  bone  may  be  easily  per- 
ceived through  the  skin,  because  the  muscles  are  inserted  nearer 
to  its  inferior  than  its  superior  aspect ;  but  in  fat  persons,  the  cel- 
lular tissue  raises  the  integuments  so  much,  that  we  cannot 
always  distinguish  the  displaced  fragments  by  means  of  the  touch, 
unless  the  fracture  exists  in  that  portion  which  is  convex  for- 
wards. 

Posteriorly,  the  attachment  of  the  trapezius  corresponds  to  that 
of  the  deltoid  :  opposite  to  the  pectoralis  major  muscle,  the  bone  is 
free,  and  its  diseases,  in  this  direction,  may  be  easily  appreciated. 
In  general,  the  clavicle  may  be  fractured  in  any  part  of  its  length ; 
but  it  is  more  frequently  broken  at  the  place  where  the  attach- 
ments of  the  deltoid  and  trapezius  terminate,  than  elsewhere  ;  and 
for  these  reasons,  because,  on  the  one  hand,  the  bone  there  affords 
less  resistance,  and,  on  the  other,  because  it  is  at  this  point  that 
the  two  curvatures  meet ;  whence  it  follows  that,  in  a  fall  upon 
the  shoulder,  for  example,  the  weight  of  the  body  and  the  resist- 
ance of  the  ground,  tend  to  cross  one  another  at  this  point  of  con- 
junction of  these  two  osseous  portions.  This  last  reason  also  ex- 
plains why  these  fractures  are  almost  always  oblique,  and  why 
the  slope  of  the  internal  fragment  most  frequently  takes  place  at 
the  expense  of  the  posterior  aspect. 

When  the  clavicle  is  fractured  by  a  direct  cause,  the  solution 
of  continuity  generally  exists  at  the  union  of  its  two  internal 
thirds,  on  account  of  the  greater  convexity  of  the  bone  at  this 
point,  which  renders  it  more  exposed  to  the  action  of  external 
violence. 

In  this  last  case  the  displacement  must  take  place  in  the  follow- 
ing manner:  the  internal  fragment  is  drawn  upwards  by  the 


•34*2  OF  THK  THOKACIC  EXTREMITIES, 

sterno-mastoid  muscle,  to  which  the  pectoralis  major  opposes  but 
a  very  feeble  resistance ;  the  external,  on  the  contrary,  being 
supported  by  the  trapezius  only,  is  drawn  downwards  and  for- 
wards, by  the  subclavius,  the  deltoid  and  the  great  pectoral. 

If  the  fracture  is  situated  in  the  point  first  indicated,  or  more 
externally,  it  is  possible  that  there  will  be  only  a  slight  degree  of 
displacement  transversely,  because  the  trapezius  and  deltoid  ex- 
ternally, the  pectoralis  major,  subclavius  and  sterno-mastoid  inter- 
nally, mutually  counterbalance  the  action  of  one  another.  As  to 
the  displacement  longitudinally,  it  manifests  itself  whatever  may 
be  the  point  of  fracture.  The  muscular  portion,  which  brings  the 
arm  in  adduction,  at  the  same  time  that  it  raises  it,  having  no  lon- 
ger a  fixed  point,  and  the  prop  which  is  placed  between  the 
shoulder  and  sternum,  no  longer  existing,  it  follows  that  these  pa- 
tients will  be  unable  to  carry  the  hand  to  the  face  without  de- 
pressing the  head.  This  phenomenon,  although  pretty  constant, 
is  not  universally  so,  and  we  have  seen,  this  year,  in  the  hospital 
of  the  Ecole  de  Medecine,  a  man  of  forty,  who  had  been  affected 
with  a  very  oblique  fracture  of  the  clavicle,  with  considerable 
overlapping,  for  three  days,  move  and  make  use  of  his  arm,  which 
he  raised  to  the  vertex  with  the  greatest  freedom.  M.  Breschet, 
surgeon  of  Hotel  Dieu,  has  recently  met  with  a  similar  example. 
Do  not  these  cases  give  support  to  the  opinion  of  those  who  ad- 
mit that  fractures  of  the  clavicle  do  not  actually  require  any  other 
apparatus  than  the  simple  supporting  bandage  (bandage  con- 
tentif)  ?  It  is  necessary  to  observe,  however,  that  by  acting  thus 
we  do  not  prevent  the  overlapping  of  the  bones,  and  the  contrac- 
tion which  may  thereby  take  place  in  the  axillary  space  may,  per- 
haps, be  carried  so  far  as  to  permit  the  compression  of  the  vessels 
and  nerves. 

(d)  The  Ribs  do  not  present  anything  very  remarkable  in  the 
sub-clavicular  region;  the  second  only,  on  account  of  the  slight 
inclination  of  its  external  surface,  and  its  more  superficial  position, 
deserves  some  attention.  It  is  upon  this  rib  that  John  Bell  ad- 
vises compressing  the  axillary  artery,  rather  than  behind  the  cla- 
vicle. We  have  already  said  that  this  precept  ought  not  to  be 
followed.  The  other  ribs,  in  this  region,  can  but  rarely  be  frac- 
tured, on  account  of  the  thickness  and  solidity  of  the  parts  which 
cover  them.  This  must  be  understood,  however,  to  refer  to  direct 


OF   THE   THORACIC    EXTREMITIES.  243 

fractures  only ;  for  those  which  originate  from  pressure  on  the 
sternum,  etc.,  may  take  place  in  these  ribs  as  well  as  in  the  others. 
These  accidents  will  even  be  more  dangerous  here  than  else- 
where, on  account  of  the  organs  contained  in  the  axilla. 

The  following  is  the  order  of  super-position  of  the  parts  in  the 
region  which  we  have  just  examined :  In  the  first  place  we  meet 
with,  from  before  backwards,  1st.  the  skin  ;  2d.  the  superficial 
layer,  including  some  fibres  of  the  platysma,  small  veins  and  fat ; 
3d.  the  thin  prolongation  of  the  aponeurosis,  or  the  cellular  la- 
mina which  covers  the  muscles ;  4th.  the  pectoralis  major  and 
minor,  the  deltoid,  an  inter-muscular  cellulo-adipose  layer ;  5th. 
the  biceps,  coraco-brachialis  and  subclavius ;  the  coraco-clavicu- 
lar  aponeurosis,  much  cellular  tissue  and  lymphatic  glands ;  6th. 
the  nerves  and  vessels ;  7th.  cellular  texture  also,  then  the  sub- 
scapularis  muscle  externally,  and  the  serratus  magnus  internally. 

Next,  from  the  base  to  the  apex  [of  the  region]  we  find, 
1st.  the  skin,  covered  with  hairs ;  2d.  the  subcutaneous  layer  ; 
3d.  the  aponeurosis ;  4th  cellular  tissue  in  great  abundance,  lym- 
phatic glands,  venous  and  arterial  ramuscules  ;  5th.  the  axillary 
artery  and  vein,  then  the  brachial  plexus ;  6th.  cellular  lamella 
filling  the  sub -clavicular  aperture. 

Sect.  2.  Posterior  Region  of  the  SItoulder,  or  Scapular  Region, 
properly  so  called. 

This  region  is  naturally  bounded,  posteriorly,  by  the  spinal 
border  of  the  scapula ;  anteriorly,  by  the  acromio-digital  line ; 
superiorly,  by  the  supra-clavicular  region  ;  and  inferiorly,  by  the 
posterior  margin  of  the  axilla. 

It  represents  a  triangle  with  its  truncated  summit  directed  for- 
wards. 

Its  surface  presents  several  prominences  and  depressions,  which 
may  easily  be  distinguished  through  the  skin :  thus,  posteriorly, 
we  may  distinctly  feel,  through  the  trapezius  muscle,  the  posterior 
margin  of  the  scapula,  likewise  the  superior  and  inferior  angles  of 
this  bone  ;  inferiorly,  the  thick  and  rounded  border  of  the  latissi- 
mus  dorsi ;  from  above  downwards  and  from  before  backwards, 
the  coracoid  process,  and  a  ridge  running  from  the  posterior  bor- 
der of  the  middle  region  of  the  shoulder,  which  corresponds  to  the 


•244 


OF    THE    TliOHACIC    EXTREMITIES. 


spine  of  the  scapula,  to  the  acromion  or  clavicle  :  still  lower,  we 
discover  another  eminence  produced  by  the  infra-spinatus  muscle. 
The  deltoid  and  the  head  of  the  os  hurneri  generally  form  a  very 
distinct  prominence  likewise.  Between  the  two  latter  eminences, 
we  observe  a  kind  of  grqove  which  runs  from  the  acromion  into 
the  cavity  of  the  axilla  and  which  we  will  call  the  posterior  deltoi- 
dal  groove ;  finally,  there  is  still  another  species  of  hollow  be- 
tween the  acromion  and  the  clavicle. 

CONSTITUENT  PARTS. 

i.  The  Skin. 

The  skin  is  thick  in  the  superior,  but  still  more  so  in  the  postS- 
rior  part  of  the  region  ;  less  so  anteriorly  and  especially  inferior- 
]y :  it  is  never  covered  with  hairs,  and  we  see  no  wrinkles  in  it, 
except  those  which  result  from  the  arrangement  of  the  papillae. 
Its  sebaceous  follicles  are  not  very  numerous,  but  are  very  large  ; 
its  vessels  form  a  complicated  plexus,  and  its  sensibility  is  suffi- 
ciently acute.  It  is  on  account  of  these  characters,  as  well  as 
the  compact  texture  and  slight  extensibility  of  the  skin,  that  the 
boils  which  are  so  frequently  developed  within  it  generally  pro- 
duce a  great  deal  of  pain,  and  appear  to  differ  but  little  from  sim- 
ple anthrax. 

ii.  The  Subcutaneous  Layer. 

This  layer  contains  a  considerable  quantity  of  arterial  and  ve- 
nous ramuscules,  but  few  nerves ;  its  adipose  cells  are  few  in 
number,  at  least  opposite  to  the  osseous  eminences :  its  cellular 
tissue  is  both  lamellated  and  filamentous  ;  it  is  supple  and  so  dis- 
posed as  to  admit  of  a  pretty  extensive  mobility  of  the  skin  over 
the  supra  and  infra-spinal  fossre ;  over  the  deltoid,  in  certain 
subjects,  it  contains  considerable  fat ;  is  dense  and  apparently 
fibrous  over  the  spine  of  the  scapula,  the  acromion  and  clavicle, 
where  it  sometimes  forms  a  complete  mucous  or  synovial  bursa. 
which  facilitates  the  movements  of  the  shoulder :  in  fine,  it  is 
pretty  intimately  united  to  the  skin,  but  is  very  readily  separable 
from  the  aponeurosis.  In  consequence  of  this  disposition,  wounds 


OP   THE    THORACIC    EXTREMITIES. 

in  the  posterior  region  of  the  shoulder,  which  do  not  extend  to 
the  muscles,  should  and  may  be  united  by  the  first  intention  by 
means  of  plaisters,  bandages  or  sutures;  but  we  must  take  care 
that  pus  or  other  fluids  do  not  accumulate  between  the  aponeuro- 
sis  and  the  wound. 

in.  The  Aponeurosis. 

It  is  formed  by  a  considerable  number  of  sheets,  which  are  at 
first  distinct  by  their  position  and  usages,  but  afterwards  become 
blended  with  those  of  the  surrounding  regions.  Thus,  one  sheet, 
the  two  lamina?  of  which  are  continuous,  before  and  behind  the 
trapezius,  with  those  of  the  back  and  neck,  descends  from  this 
muscle  towards  the  superior  margin  of  the  latissimus  dorsi,  where 
it  splits  in  order  to  envelope  the  latter  muscle,  and  afterwards 
becomes  continuous  with  the  brachial  aponeurosis.  This  sheet  is 
generally  thin  upon  the  muscles,  where  it  merely  represents,  if  I 
may  so  say,  a  simple  cellular  layer.  In  the  interval  which  sepa- 
rates them,  below  the  spine,  it  is  thicker  and  evidently  fibrous. 
Although  dense,  it  nevertheless  always  preserves  a  certain  degree 
of  extensibility,  which  prevents  its  being  confounded  with  the 
other  laminas  of  this  region. 

Of  these  laminae,  there  is  one  which  originates  from  the  inferior 
margin  of  the  spine  and  the  posterior  border  of  the  scapula,  and 
passes  towards  the  side  of  this  bone,  dividing  in  such  a  manner  as 
to  form  two  intersections  between  the  teres  major,  teres  minor  and 
infra-spinatus  muscles ;  after  which  it  becomes  continuous  with 
the  preceding  sheet  under  the  axilla.  On  the  other  side,  it  also 
splits  on  a  level  with  the  posterior  deltoidal  border,  so  that  one  of 
its  lamellae,  which  is  the  thinnest,  applies  itself  upon  the  deltoid 
muscle,  becomes  blended  with  the  superficial  sheet  which  has  just 
been  examined,  and  is  lost  in  the  aponeurosis  of  the  superior  ex- 
tremity ;  the  other  remains  under  the  deltoid,  forms  a  pretty  com- 
pact sheath  for  the  infra-spinatus  muscle,  which  it  follows  to  the 
head  of  the  humerus,  where  it  is  confounded  with  the  articular 
capsule.  We  might  call  this  the  infra-spinal  aponeurosis. 

Finally,  we  find  a  third  lamina  above  the  spine  of  the  scapula : 
this  binds  down  the  supra-spinatus  muscle,  and  is  confounded, 
anteriorly,  with  the  coraco-clavicular  and  acromio-clavicular  liga- 


OF   THE    THORACIC    EXTREMITIES. 

ments,  behind  the  clavicle  and  the  capsule  of  the  joint.  We  can 
conceive  how  important  it  is  to  be  well  acquainted  with  the  ar- 
rangement of  these  aponeuroses,  when  we  wish  to  ascertain  the 
seat  and  danger  of  abscesses  or  other  affections  at  the  posterior 
part  of  the  shoulder. 

iv.  The  Muscles. 
i 

In  order  to  have  an  exact  idea  of  these  organs  in  the  scapulary 
region,  it  is  necessary  to  divide  it  into  four  portions ;  which  are  : 
1st,  the  Supra-Spinal ;  '2d,  the  Infra-Spinal ;  3d,  the  Axillary  ; 
4th,  the  Humeral. 

(  a  )  In  the  first  (supra-spinal),  we  find  the  trapezius,  which  is 
inserted  into  the  superior  border  of  the  spine  of  the  scapula,  from 
its  tubercle  as  far  as  the  clavicle.  The  fibres  of  this  muscle,  in 
this  point,  being  oblique  upwards  and  backwards,  it  follows  that 
when  they  contract  they  must  raise  the  shoulder.  It  is  separated 
from  the  supra-spinal  aponeurosis  by  a  cellular  layer,  sometimes 
of  moderate  thickness,  which  establishes  a  communication  with 
the  supra-clavicular  and  axillary  regions. 

Next  the  Angularis,  which  is  in  fact  only  a  digitation  of  the 
serratus  major  anticus*,  and  which  appertains  to  the  regions  of 
the  neck.  With  respect  to  the  shoulder,  we  see  that  it  tends  to 
draw  up  the  posterior  angle  of  the  scapula,  and  that  if  this  bone 
was  fractured  transversely,  it  would  separate  the  fragments  con- 
siderably. 

After  the  angularis,  is  the  omo~hyoideus,  another  muscle  of  the 
supra-clavicular  region.  As  this  fasciculus  is  attached  to  the  su- 
perior costa  of  the  bone,  behind  the  coracoid  notch,  its  action 
upon  the  shoulder  must  be  very  slight ;  on  the  contrary,  it  derives 
from  this  bone  its  fixed  point,  in  order  to  depress  the  larynx.  As 
it  ascends,  it  leaves  between  it  and  the  coracoid  process  a  small 
triangular  space,  through  which  the  supra-scapulary  nerve  and 
vessels  occasionally  pass,  previous  to  their  entrance  into  the  supra- 
spinal  fossa. 

Finally,  the  Supra-spinatus  Muscle,  which  fills,  and  is  firmly 
fixed  in  the  fossa  of  the  same  name,  by  the  aponeurosis.  It 

*  M.  Dumeril. 


OF   THE    THORACIC    EXTREMITIES.  24? 

should  be  observed  that  in  passing  under  the  acromio-clavicular 
arch,  it  is  applied  directly  upon  the  articulation,  as  well  as  upon 
the  head  of  the  humerus,  previous  to  its  insertion  into  the  trochi- 
ter,  and  that  it  there  slides  in  a  supple  fibre-cellular  tissue,  which 
communicates  with  the  axilla  by  the  posterior  surface  of  the 
deltoid. 

(  b  )  In  the  Infra-spinal  portion  we  find,  posteriorly,  near  the 
spine,  a  small  portion  of  the  trapezius.  Here,  this  muscle  is  con- 
verted into  a  strong  aponeurosis,  which  fixes  it  to  the  tubercle  of 
the  osseous  crista.  There  is  generally  a  bursa  mucosa  under  this 
aponeurotic  triangle. 

Posteriorly  also,  but  still  more  inferiorly,  we  find  a  small  por- 
tion of  the  latissimus  dorsi.  Sometimes  this  muscular  bundle  is 
attached  to  the  angle  of  the  scapula,  at  other  times  it  only  slides 
over  this  bone  as  it  is  passing  into  the  axillary  portion  of  the 
region.  In  either  case  this  muscle,  as  well  as  the  trapezius, 
principally  acts  here  by  pressing  the  scapula  against  the  thorax. 

Anteriorly,  we  observe  the  scapular  portion  of  the  deltoid,  the 
border  of  which  becomes  more  and  more  isolated  in  proportion 
as  it  approximates  the  humerus.  Between  this  border,  the  tra- 
pezius and  latissimus  dorsi,  there  is  a  triangular  space,  of  a  cer- 
tain extent,  in  which  the  skin  is  only  separated  from  the  infra- 
spinatus  muscle  by  the  aponeuroses.  Under  this  space  and  the 
preceding  muscles,  we  meet  with  the  infra-spinatus. 

This  muscle  originates  from  and  fills  the  fossa  infra-spinata,  but 
is  less  and  less  adherent  to  it  in  proportion  as  it  proceeds  for- 
wards ;  covered  by  the  deltoid,  it  passes  under  the  acromion ; 
its  tendon  approximates  the  supra-spinatus,  crosses  the  articula- 
tion in  the  same  manner,  and  gliding  under  the  acromial  arch  is 
inserted  into  the  trochiter.  It  is  equally  enveloped  by  the  cellu- 
lar tissue  which  forms  a  communication  between  its  fossa  and 
the  cavity  of  the  axilla.  It  is  important  to  notice  that  as  the 
supra1  and  infra-spinata  muscles  are  enclosed  in  a  species  of  sac, 
which  is  fibrous  behind  and  osseous  before,  abscesses  which  form 
in  their  substance,  or  in  their  sheath,  cannot,  without  difficulty, 
make  their  way  out  in  any  other  direction  than  by  that  which 
leads  to  the  axilla. 

(  c )  The  Axillary  portion  includes  the  latissimus  dorsi,  the  teres 
major,  and  teres  minor ;  but  only  the  fleshy  portion  of  these  mus- 


248 


OF   THE   THORACIC    EXTREMITIES. 


cles.  The  two  former  are  separated  by  a  sheet  of  the  super- 
ficial aponeurosis,  but  soon  become  confounded  with  each  other : 
as  they  remove  from  the  third,  they  slide  upon  the  humenis 
anterior  to  the  triceps,  which  separates  their  tendon  from  the 
deltoid.  As  the  teres  major  acts  upon  the  inferior  angle  of 
the  scapula,  when  the  arm  is  fixed,  as  upon  a  lever  of  the  first 
order,  it  thence  follows  that,  in  order  to  consolidate  fractures  of 
the  os  humeri,  the  arm  must  be  retained  close  to  the  trunk.  The 
teres  minor,  which  appears  to  be  only  a  fascis  detached  from 
the  infra-spinatus,  ascends  parallel  to  the  latter  under  the  deltoid, 
in  order  to  fix  itself  to  the  great  tubercle  (irochiter)  of  the  os 
brachii ;  so  that,  when  it  acts  upon  this  bone,  it  may  be  consid- 
ered as  the  antagonist  of  the  sub-scapularis.  The  space  which 
separates  it  from  the  teres  major  is  filled  with  cellular  tissue,  and 
encloses  the  posterior  branches  of  the  sub-scapulary  vessels.  As 
it  is  on  the  outer  side  of  the  joint,  its  anterior  surface  rests  upon 
the  long  portion  of  the  triceps. 

(  d  )  In  the  humeral  portion  we  observe  the  middle  bundle  of 
the  deltoid,  the  curved  fibres  of  which,  in  raising  the  arm  when 
it  is  free,  act  upon  the  os  humeri  as  upon  a  lever  of  the  third 
order.  But,  when  the  moveable  extremity  of  the  limb  is  retained 
by  some  power,  this  muscle  might  depress  the  head  of  this  bone, 
and  thus  favour  the  luxation  downwards.  This  fascis  is,  as  it 
were,  moulded  upon  the  articulation,  from  which,  however,  when 
the  arm  is  pendent  by  the  side  of  the  thorax,  it  is  separated  by  a 
space  of  almost  an  inch.  A  broad  kind  of  bursa  mucosa  exists 
in  this  space,  which  in  general  contains  but  a  small  quantity  of 
fluid. 

(e)  Upon  the  humerus,  properly  so  called,  we  find  the  extrem- 
ity of  the  three  portions  of  the  triceps,  of  which  the  external 
(great  head)  is  nearest  to  the  deltoid,  and  is  occasionally  contin- 
ued by  its  extremity  as  far  as  the  tendon  of  the  teres  minor. 
The  middle  portion  (long  head)  gradually  detaches  itself  from 
the  humerus,  and  passes  upon  the  inferior  costa  of  the  scapula, 
to  which  it  is  attached  about  half  an  inch  below  the  glenoid  cav- 
ity. It  then  becomes  flattened,  and  its  posterior  surface  is  con- 
cealed by  the  teres  minor,  and  lower  down  by  the  brachial  apo- 
neurosis. Anteriorly,  this  muscle  rests  upon  the  broad  tendons 
of  the  latissirnus  dorsi  and  teres  major,  beyond  which  it  is  free  in 


OF    THE    THORACIC    EXTREMITIES. 

the  hollow  of  the  axilla ;  and,  close  to  its  attachment,  it  rests 
partially  upon  the  subscapularis  muscle.  When  the  arm  is  fixed, 
this  muscular  bundle  acts  upon  the  scapula  in  the  same  manner 
as  the  teres  major ;  with  this  difference,  however,  that  here  this 
action  inclines,  in  great  part,  to  the  profit  of  the  solidity,  because 
the  branch  of  the  lever  is  considerably  shortened.  Relative  to 
the  articulation,  when  the  arm  is  raised,  the  triceps  represents  a 
tense  cord,  which  opposes  luxation  downwards  by  supporting  the 
head  of  the  humerus ;  but  in  fractures  of  the  neck  of  this  bone, 
it  tends  to  displace  the  fragments  in  a  longitudinal  direction. 

As  the  tendons  of  the  latissimus  dorsi  and  teres  major  are  in- 
serted into  the  posterior  labium  of  the  bicipital  groove,  they  must 
turn  the  arm  outwards  ;  and,  as  their  inferior  margin  is  continu- 
ous with  the  brachial  aponeurosis,  this  fibrous  sheet  is  very  appa- 
rent when  these  muscles  contract.  We  will  soon  re-examine 
the  supra  and  infra-spinatus  muscles  and  teres  minor. 

v.  The  Arteries. 

(a)  They  are  derived  from  the  supra-scapulary,  the  transverse 
cervical,  the  subscapulary  and  circumflex  arteries. 

The  first  (Supra-scapulary)  plunges  into  the  fossa  supra-spinata, 
often  above  and  sometimes  below  the  ligament  which  converts 
the  coracoid  notch  into  a  foramen.  The  branches  which  it  here 
gives  off,  and  which  are  here  distributed  to  the  trapezius,  supra- 
spinatus,  angularis,  etc.,  muscles,  are  generally  so  small  that  they 
do  not  require  a  ligature  when  we  perform  operations  upon  these 
parts.  One  of  its  branches  remains  in  the  fossa  supra-spinata ; 
the  other  goes  under  the  spine  of  the  scapula,  passing  under  the 
acromion,  behind  the  glenoid  cavity,  and  is  lost  in  the  infra-spina- 
tus, teres  minor  and  major  muscles.  This  artery  is  important 
in  surgery  only  in  relation  to  its  numerous  anastamoses. 

(  b  )  The  Transverse  Cervical  arises  from  the  same  trunk  with 
the  supra-scapulary,  and  gives  to  the  region  of  the  shoulder  its 
descending  branch  only ;  it  sends  off  twigs  which  pass  between 
the  rhomboideus  and  trapezius,  or  which  perforate  the  first  of 
these  muscles  and  anastamose  with  the  rarnuscules  of  the  prece- 
ding in  the  fossa  infra-spinato. 

32 


250  OF    THE    THORACIC    EXTREMITIES. 

(c)  The  third  (subscapularis)  comes  from  the  axilla,  and  pas- 
ses through  the  opening  which  is  circumscribed  by  the  teres 
major  and  subscapularis  muscles  on  the  one  part,  and  the  long 
portion  of  the  triceps  on  the  other ;  it  ascends  between  the  teres 
minor  and  the  anterior  costa  of  the  scapula,  an  inch  and  a  half 
below  the  glenoid  cavity ;  the  largest  of  its  branches  dips  imme- 
diately into  the  subscapulary  fossa  ;  the  others  pass  into  the  del- 
toid towards  the  acromion ;  finally,  a  considerable  number  enter 
the  latissimus  dorsi,  the  teres  major,  etc.  As  it  comes  out  of  the  ax- 
illa, this  artery  is  sometimes  of  considerable  size  ;  so  that  a  wound 
penetrating  into  the  scapulo-humeral  or  posterior-deltoid  groove, 
might  give  rise  to  a  troublesome  haemorrhage.  In  such  a  case,  or 
for  any  other  reason,  it  might  be  exposed,  by  making  an  incision 
parallel  to  the  anterior  costa  of  the  scapula,  but  upon  the  exter- 
nal face  of  the  deltoid.  Then,  by  dividing  the  posterior  border 
of  this  muscle,  opposite  to  the  point  of  intersection  of  the  teres 
minor  and  the  long  portion  of  the  triceps,  we  will  easily  find 
this  vessel  by  holding  the  arm  very  much  upwards  and  back- 
wards :  so  that,  in  order  to  reach  it,  we  will  have  to  cut,  1st.  the 
skin  ;  2d.  the  adipose  layer ;  3d.  the  aponeurosis ;  4th.  the  fibres 
of  the  deltoid ;  5th.  the  cellular  tissue.  The  teres  minor  must 
be  pushed  backwards. 

(  d  )  The  Posterior  Circumflex,  as  we  have  already  stated, 
turns  round  the  bone,  and  is  only  separated  from  that  which  we 
have  just  considered  by  the  scapulary  portion  of  the  triceps 
muscle.  It  is  distributed  almost  entirely  to  the  deltoid,  and 
anastamoses  very  freely  with  the  anterior  circumflex,  the  acromi- 
al,  the  supra- scapuiary  and  the  preceding  branch. 

These  are  the  arterial  communications  by  which  the  circulation 
in  the  arm  is  supported,  when  we  tie  the  sub-clavian  or  axillary 
arteries.  Thus,  the  acromial  with  the  subscapulary  and  circum- 
flex, on  the  one  hand,  and,  on  the  other,  with  the  supra-scapula- 
ry ;  the  subscapulary  with  the  transverse  cervical  and  the  exter- 
nal mammary ;  the  latter  with  the  internal  mammary  and  tho 
anterior  thoracics,  etc.,  are  quite  sufficient  to  carry  the  blood 
from  the  point  above  the  ligature  of  tiie  principal  artery  to  the 
parts  below,  without  taking  into  consideration  other  branches 
which  it  is  needless  to  mention. 


OF   THE    THORACIC    EXTREMITIES.  251 


vi.  The  Veins.   * 

All  the  veins  of  this  region  follow  the  direction  of  the  arteries, 
to  which,  in  general,  they  are  somewhat  intimately  adherent ;  but 
they  are  much  larger;  their  capillary  system  in  particular  is 
very  abundant ;  hence  the  frequency  of  nsevi  materni,  spongy 
(erectile)  tumours,,  and  fungus  hcematodes  in  the  region  of  the 
shoulder. 

vii.  The  Lymphatics. 

These  organs  present  nothing  peculiar  in  this  region.  Like 
those  of  other  parts,  they  consist  of  two  series;  one  of  which  is 
superficial,  passing  almost  entirely  to  the  axillary  glands;  the 
other,  deep  seated,  accompanying  the  veins,  and  entering  into  the 
supra-clavicular  and  axillary  regions. 

viii.  The  Nerves. 

They  are  very  numerous,  but  of  moderate  size,  and  consist  of 
the  terminations  of  the  spinal  accessory,  supra-scapulary,  arid  the 
circumflex  which  is  the  principal  nerve  of  this  region. 

(  a  )  The  Spinal  ramifies  in  the  trapezius,  and  does  not  appear 
to  send  filaments  to  the  skin  ;  so  that  it  is  probably  destined  only 
for  the  contractions  of  this  muscle.  Consequently,  if  it  was  divi- 
ded, such  division  would  produce  paralysis  of  the  movements  of 
elevation  and  abduction  of  the  stump  of  the  shoulder. 

(  b  )  The  Supra-Scapulary  comes  from  the  supra-clavicular 
region :  it  passes  into  the  coracoid  notch,  gives  filaments  to  the 
supra-spinatus  muscle,  then  descends  into  the  fossa  infra-spinata, 
where  it  divides  like  the  artery  of  the  same.  It  anastomoses  with 
the  scapulary  and  supra-acromial  filaments.  As  it  is  situated  be- 
hind the  glenoid  cavity,  it  runs  no  risk  of  being  injured  from  am- 
putations, or  luxations ;  but  if  the  neck  of  the  scapula  was  frac- 
tured, it  might  give  rise  to  unpleasant  symptoms. 

(  c  )  The  Supra-Acromial  Nerves  are  derived  from  the  cervi- 
cal plexus,  and  appear  to  be  distributed  to  the  skin.  The  bra- 
chial  plexus  gives  off  the  fmb-scap*kiHe$,  which  pass  into  the  a*- 


01     THE    THORACIC    EXTREMITIES. 

illary  muscles  of  the  posterior  region  of  the  shoulder.     They  are 
scarcely  susceptible  of  surgical  applications. 

(  d  )  The  Circumflex  is  much  more  important ;  its  volume  is 
sometimes  equal  to  that  of  the  radial.  As  it  comes  out  of  the 
axilla  it  passes  under  the  neck  of  the  humerus  by  the  sub-scapula- 
humeral  aperture ;  it  is  included  in  the  same  cellular  sheath  with 
the  artery  and  veins,  remains  in  contact  with  the  bone  for  a  long 
time,  and  is  lost  in  the  deltoid,  of  which  it  is  the  nervus  proprius, 
and  in  the  circumference  of  the  articulation.  From  this  disposi- 
tion, we  may  easily  comprehend  how  it  is  that  pressure  of  this 
nerve  suspends  almost  all  the  motions  of  the  arm,  and  that  the 
head  of  the  humerus,  when  luxated,  may  produce  this  phenome- 
non. We  also  conceive  that  in  fractures  of  the  neck  very  high 
up,  the  circumflex  nerve  is  still  more  exposed  to  laceration, 
stretching  and  even  compression,  than  in  the  articulatory  displace- 
ments. 

ix.  The  Skeleton. 

It  is  composed  of  the  whole  of  the  scapula,  of  the  acromio- 
clavicular  and  scapulo-humeral  articulations. 

In  the  scapula  and  the  other  osseous  parts  we  should  note, 

1st.  The  Fossa  Supra- Spinala,  the  inner  wall  of  which  is  so 
thin  that  a  pointed  instrument  may  perforate  it  without  difficulty, 
and  thereby  wound  important  organs  in  the  axilla. 

2d.  The  Fossa  Infra- Spinata,  which  is  not  much  thicker ;  but 
here  the  same  wound  would  produce  accidents  of  a  different  na- 
ture. For,  as  the  brachial  plexus  is  more  anterior,  it  would  proba- 
bly not  be  touched,  and  the  vulnerant  body  would  be  more  liable 
to  penetrate  into  the  cavity  of  the  thorax.  This  portion  of  bone 
may  be  fractured;  but  as  the  aponeurosis  adheres  to  its  whole 
circumference  and  the  infra-spinatus  muscle  is  attached  to  its 
surface,  they  must  prevent  all  manner  of  displacement,  and  reduce 
the  method  of  treatment  to  retentive  bandages  simply ; 

3d.  Its  Spine.  The  triangular  surface  which  forms  the  root  of 
the  posterior  border  of  this  process  permits  the  trapezius  to  slide 
upon  it,  when  its  inferior  fibres  contract,  as  over  a  pulley.  It  is 
so  disposed  that  the  deltoid,  which  elevates  the  arm,  and  the  tra- 
pezius, which  draws  up  the  shoulder,  derive  from  it  at  the  same 


OF    THE    THORACIC    EXTREMITIES. 

lime  their  fixed  or  moveable  point;  from  which  circumstance 
these  two  muscles  are  almost  always  obliged  to  combine  their 
actions.  As  this  osseous  crest  can  always  be  felt  through  the 
skin,  it  follows  that  when  the  shoulder  of  the  foetus  presents 
during  labour  it  may  be  mistaken  for  the  clavicle,  and  thereby 
lead  to  an  incorrect  manoeuvre  in  the  attempt  to  turn  the  child. 

4th.  The  Acromion,  which  is  only  the  continuation  of  the  pre- 
ceding spine,  is  inclined  slightly  outwards  and  projects  at  least 
eight  lines  before  the  glenoid  cavity ;  so  that  a  luxation  of  the 
humerus  cannot  take  place  in  this  direction  without  a  fracture  of 
this  process.  In  powerful  muscular  subjects,  especially  those  who 
exercise  their  arms  very  much,  the  acromion  is  thicker,  stronger, 
and  curved  more  downwards;  so  that  its  beak  is  sometimes 
closely  approximated  to  the  head  of  the  humerus :  such  a  dispo- 
sition might  increase  the  difficulty  of  amputating  the  arm  at  the 
shoulder  joint,  according  to  Lisfranc's  method.  The  apex  of  the 
acromion,  as  well  as  the  external  extremity  of  the  clavicle,  re- 
main cartilaginous  until  about  the  age  of  fifteen  years  ;*  in  which 
case,  if  the  acromio-clavicular  vault  was  diseased  in  such  a  man- 
ner as  to  require  its  removal,  the  cutting  instrument  would  easily 
divide  these  parts  and  render  the  saw  unnecessary.  The  same 
would  apply  to  the  extirpation  of  the  arm.  But  we  do  not  see 
that  it  would  be  necessary  to  remove  these  parts  in  the  latter 
operation ;  on  the  contrary,  they  should  be  left  unmolested,  on 
account  of  the  muscles  which  are  attached  to  them,  and  which 
are  subservient  to  the  formation  of  the  flap.  We  have  several 
times  observed  the  acromion  process  united  to  the  spine  of  the 
scapula,  in  subjects  of  thirty  years,  merely  by  a  thin  vinculum  of 
cartilage.  In  a  like  case  we  consider  that  a  fracture,  or  rather  a 
disjunction  of  the  epiphysis,  might  easily  take  place.  The  ana- 
tomical disposition  of  this  process  is  such  that,  when  fractured, 
the  anterior  fragment  may  be  forcibly  drawn  downwards  by  the 
action  of  the  deltoid  muscle  and  the  weight  of  the  limb:  hence 
the  rule  for  keeping  the  arm  firmly  elevated  in  fractures  of  the 
acromion. 

5th.  The  Coracoid  process,  which  completes  internally  the  canal 
through  which  the  tendon  of  the  supra-spinatus  muscle  passes : 

*  M.  Lisfranc.    Archives,  Mai  1824. 


254  OF    THE    THORACIC    EXTREMITIES. 

it  is  its  dorsal  aspect  which  serves  as  the  point  of  support  to  the 
clavicle  when  its  sternal  extremity  is  depressed.  The  conoid 
and  trapezoid  ligaments,  which  limit  the  elevation  of  the  latter 
bone,  here  deserve  some  attention.  In  fact,  they  are  very  short, 
very  thick,  and  consequently  very  strong:  their  arrangement, 
also,  is  such  that  the  clavicle  cannot  be  carried  more  than  a  few 
lines,  either  forwards  or  backwards,  without  putting  them  very 
much  on  the  stretch,  and  thereby  opposing  these  motions. 

6th.  The  Clavicle.  This  bone  is  flat  and  spongy  between  the 
two  preceding  processes,  and  is  about  an  inch  and  a  half,  or  at 
most,  two  inches  in  length.  Fractures  occurring  in  this  portion 
of  the  bone  cannot  be  attended  with  displacement  in  a  longitu- 
dinal direction,  because  the  acromion  on  the  one  hand,  and  the 
coracoid  process  on  the  other,  invincibly  restrain  the  fragments 
from  crossing  each  other.  Between  the  spine  of  the  scapula, 
the  base  of  the  coracoid  process  and  the  clavicle,  we  observe  a 
retiring  angle  (angle  rentrant)  \vhich  is  filled  by  the  trapezius 
muscle.  Before  the  clavicle,  we  observe  the  small  coraco-acro- 
mial  triangle,  closed  by  the  ligament  of  the  same  name,  at  which 
we  introduce  the  point  of  the  knife  into  the  articulation.  Finally, 
notwithstanding  this  articulation  of  the  clavicle  consists  in  the 
mere  application  of  simple  surfaces,  yet  the  superior  and  inferior 
ligaments,  and  all  the  parts  which  unite  the  clavicle  to  the  acro- 
mion, are  so  compact  that  its  dislocations  are  difficult  and  unfre- 
quent.  It  must  be  admitted,  however,  that  the  infrequency  of 
these  displacements  are  also  to  be  attributed  to  other  anatomical 
peculiarities :  thus,  for  example,  in  consequence  of  the  great 
mobility  of  the  scapula,  the  two  bones  of  the  shoulder  always 
move  together ;  the  sternal  extremity  of  the  clavicle  being  fixed, 
the  powers  act  but  with  difficulty  upon  it,  after  the  manner  of  a 
lever  of  the  first  species,  in  order  to  produce  this  luxation  up- 
wards ;  and  the  coracoid  process  opposes  the  dislocation  of  the 
bone,  which  surmounts  it,  downwards.  We  must  not,  however, 
with  some  moderns,  deny  the  possibility  of  the  latter  accident, 
admitted  perhaps  too  lightly  by  J.  L.  Petit. 

7th.  The  Scapulo-humeral  articulation,  which  comprises  the 
head  of  the  humerus,  the  glenoid  cavity,  and  the  fibrous  parts. 

The  head  of  the  os  brachii  represents  a  half  sphere,  which  is 
proportionately  larger  in  children  than  in  adults ;  its  axis  is  di- 


OF    THE    THORACIC    EXTREMITIES. 

reeled  obliquely  forwards,  outwards,  and  downwards,  so  that  at 
its  junction  with  the  humerus  it  forms  an  elbow  which  makes  it 
appear  longer  inferiorly,  internally,  and  posteriorly.  At  the 
point  of  this  union  there  is  a  groove  which  increases  in  depth  in 
proportion  as  it  advances  in  the  direction  last  indicated.  This 
circular  groove,  which  is  the  true  anatomical  neck  of  the  bone, 
deserves  the  greatest  attention  whenever  we  wish  to  disarticulate 
the  arm,  and  more  especially  when  we  follow  the  process  of 
Beclard.  It  is  upon  this  groove,  in  fact,  that  the  knife  must  be 
perpendicularly  carried,  if  we  wish  to  divide  the  capsule  and  the 
tendons  effectually ;  otherwise  these  parts  will  become  folded,  or 
roll  under  the  instrument,  and  the  section  be  executed  with  diffi- 
culty. It  is  necessary  then  to  recollect  the  axis  of  this  groove 
exactly,  and  the  plane  of  the  circle  which  it  forms.  There  are 
some  individuals  in  whom  the  head  of  the  humerus  continues  for 
a  long  time  in  the  state  of  epiphysis ;  it  may  then  be  detached,  and 
this,  without  doubt,  is  what  has  usually  been  denominated  a  frac- 
ture of  this  part.  We  conceive  that  the  consolidation  of  such 
fractures  is  scarcely  possible,  except  in  young  subjects,  and  when 
it  advances  a  little  upon  the  body  of  the  bone ;  for  as  the  frag- 
ment included  within  the  capsule  has  no  ligamentum  proprium. 
and  is  not  covered  by  the  periosteum,  it  will  be  completely  sepa- 
rated from  the  living  organs.  The  dimensions  of  the  head  of 
the  os  humeri  are  much  greater  than  those  of  the  glenoid  cavity; 
so  that,  were  it  not  for  the  muscles  which  surround  the  joint,  the 
weight  of  the  limb  alone  would  be  sufficient  to  produce  its  luxa- 
tion. This  is  not  founded  upon  reasoning  alone,  for  it  has  actually 
been  ascertained  that  these  dislocations  sometimes  take  place 
spontaneously  in  paralytic  individuals.  In  these  cases,  the  mus- 
cles of  the  shoulder  having  lost  their  tonic  power,  as  well  as  their 
voluntary  contractility,  cease  to  support  the  humerus,  which  is 
then  supported  merely  by  its  capsule.  Therefore,  as  the  latter 
permits  the  surfaces  to  be  separated  as  much  as  an  inch  asunder, 
it  follows  that  the  least  effort  may  draw  the  head  of  the  bone  in 
this  or  that  direction. 

With  respect  to  luxations  of  the  shoulder  generally,  we  will 
now  readily  comprehend  the  manner  and  direction  in  which  they 
may  take  place. 

Taking  the  axis  of  the  hoad  of  the  humerus  for  tho  point  of 


OF    THE    THORACIC    EXTREMITIES. 

departure,  we  see  that,  in  carrying  the  arm  inwards,  the  thorax 
will  check  its  adduction  before  this  axis  has  escaped  from  the 
glenoid  cavity ;  besides,  the  capsule,  strengthened  externally  by 
the  tendons  of  the  infra-spinatus  and  teres  minor  muscles,  will 
oppose  a  resistance  in  this  direction  almost  insurmountable. 

If  we  carry  the  arm  backwards,  the  movement  of  this  axis  will 
soon  be  stopt  by  insuperable  powers ;  thus,  the  supra-spinatus 
and  deltoid  will  hinder  it  from  rolling  too  far  forwards  ;  and  if  it 
tends  to  slip  directly  upwards,  the  capsule,  strengthened  by  the 
coraco-humeral  ligament  and  the  arch  which  is  formed  above  by 
the  coracoid  process,  acromion  and  clavicle,  will  not  permit  it  to 
pass  beyond  the  glenoid  cavity. 

If,  on  the  contrary,  it  is  inwards  that  the  head  of  the  humerus  ro- 
tates, several  circumstances  will  favour  its  escape  in  this  direction. 
First,  nothing  bounds  the  movement  of  abduction  outwards  and 
backwards  ;  next,  if  the  arm  is  elevated,  the  deltoid  may  favour 
this  movement  in  a  very  evident  manner,  and  lastly  the  fibrous 
membrane  of  the  joint  is  much  thinner  at  its  internal  part,  than 
outwards  and  upwards ;  sometimes,  it  is  even  found  reduced  to 
a  synovial  lamina  and  supported  merely  by  the  tendon  of  the 
subscapularis ;  This  tendon,  it  is  true,  is  very  strong,  and,  as  the 
head  of  the  bone  tends  to  remove  from  it  by  curving  it,  it  repels 
or  depresses  it  towards  the  cavity  from  which  it  is  disposed  to 
escape,  with  so  much  the  greater  force  in  proportion  as  its  draws 
near  the  moment  of  abandoning  the  glenoid  cavity.  But  it  is 
below  in  particular  that  luxations  take  place  with  most  facility. 

Let  us  suppose,  for  instance,  that  the  arm  is  elevated  to  a  right 
angle  with  the  trunk,  the  elbow  being  fixed:  in  this  position, 
the  axis  of  the  head  of  the  humerus  is  very  near  the  inferior 
margin  of  the  glenoid  cavity.     Then  the  deltoid,  pectoralis  major, 
latissimus  dorsi  and  teres  major  will  become  auxiliaries  to  the 
displacing  powers,  and  the  only  resistance  which  the  latter  will 
meet  wnth  will  be  in  the  lower  portion  of  the  capsule.     Now  this 
capsule  is  also  very  thin  here,  and  is  besides  but  feebly  supported 
by  the  tendinous  portion  of  the  long  head  of  the  triceps.     The 
dislocation  directly  downwards  then,  is  very  easily  produced ;  but 
as,  in  this  case,  the  head  of  the  humerus  rests  only  upon  the  side 
of  the  scapula,  and  as  the  limb  is  elongated,  the  triceps  and  sub- 
scapularis muscles  being  put  upon  the  stretch  will  almost  always 


OF    THE    THORACIC    EXTREMITIES.  257 

draw  it  inwards,  and  place  it  between  the  latter  muscle  and  the 
scapula.  It  is  possible,  however,  for  it  to  slip  outwards  likewise 
into  the  fossa  infra-spinata ;  but  the  capsular  ligament  is  stronger 
in  this  direction  ;  the  muscles  oppose  it  more  directly ;  the  costa 
of  the  scapula  is  inclined  outwards,  and  besides  it  is  rare  that  the 
free  extremity  of  the  limb  is  placed  in  a  suitable  direction  for 
favouring  this  displacement. 

We  may  further  remark,  with  respect  to  the  head  of  the  hume- 
rus,  that  the  tendons  which  are  inserted  into  its  tuberosities,  are 
so  disposed,  that,  in  fractures  of  its  neck,  they  mutually  neutralize 
each  other's  action,  so  that  they  displace  the  superior  fragment  but 
slightly.  Thus,  the  sub-scapularis,  teres  minor,  and  infra-spioatus 
counteract  one  another,  and  together  annul  what  might  be  effected 
by  the  supra-spinatus. 

The  glenoid  cavity  is  very  superficial  in  comparison  with  the 
volume  of  the  semi-sphere  which  rotates  upon  it ;  which  disposition 
is  necessary,  however,  for  the  extensive  and  varied  movements 
of  the  superior  extremity.  The  perpendicular  diameter  of  this 
cavity  is  much  greater  than  its  horizontal,  a  circumstance  to  be 
kept  in  mind  when  we  disarticulate  the  arm.  It  must  also  be 
remembered,  on  this  occasion,  that  the  coraco-acromial  arch  is 
nearly  an  inch  above  it ;  whence  it  follows  that  between  the 
summit  of  the  acromion  and  the  lower  part  of  the  glenoid  cavity 
there  exists  a  space  of  about  two  inches  and  a  half,  whilst,  trans- 
versely, this  space  is  scarcely  an  inch. 

Therefore,  in  order  to  amputate  the  arm  at  the  joint,  two 
general  methods  have  been  recommended.  In  the  one,  the  flaps 
are  always  parallel  to  the  small  diameter  of  the  space  indicated 
above  ;  in  the  other,  on  the  contrary,  they  are  perpendicular  to  it. 

Should  we  perform  the  first,  in  making  an  inferior  flap  only,  as 
practised  by  Ledran,  or  a  superior,  according  to  La  Faye ;  or 
should  we  form  two,  in  imitation  of  Garengeot  or  M.  Dupuytren, 
we  see  that  the  enormous  distance  which  separates  the  base  of 
these  two  flaps  will  always  render  it  very  difficult  to  produce  an 
immediate  re-union,  and  will  very  frequently  dispose  to  the  forma- 
of  abscesses. 

The  conjoined  method  of  MM.  de  Champesmes  and  Lisfranc, 
may  secure  the  patient  from  some  one  of  these  inconveniences  •" 
for,  if  the  knife  is  introduced  at  the  coraco-acromial  triangle,  in 

33 


£58 


Of    THE    THORACIC    EXTREMITIES. 


order  to  traverse  the  articulation,  it  is  possible  to  make  its  point 
come  out  sufficiently  low,  under  the  external  margin  of  the  acro- 
mian,  to  produce  a  flap  more  lateral  than  superior ;  but  then  this 
process  will  enter  into  the  second  method. 

It  is  to  the  latter  that  the  methods  of  Sharpe  and  Bromfield 
appertain,  and  especially  that  of  Desault.     Whether  we  make  an 
internal  flap,  by  carrying  the  knife  on  the  inner  side  of  the  hume- 
rus,  from  the  apex  of  the  acromion  behind  the  anterior  border  of 
the  axilla,  as  directed  by  Desault,  in  order  to  pass  afterwards 
through  the  articulation  and  form,  in  finishing  the  incision,  an  ex- 
ternal flap ;  or,  on  the  contrary,  we  commence,  according  to  MM. 
Larrey,  Roux,  etc.,  with  the  external  flap  and  terminate  with  the 
internal ;  or,  as  recommended  by  M.  Dupuytren,  instead  of  form- 
ing this  first  flap  by  cutting  from  within  outwards,  we  make  a 
semilunar  incision  from  the  integuments  towards  the  posterior 
part  of  the  capsule  ;  or,  finally,  whether  we  cut  the  flap  by  car- 
rying the  point  of  the  knife  before  the  posterior  margin  of  the 
axilla,  in  order  to  make  it  traverse  the  articulation  by  pushing  it 
upwards  and  forwards,  so  that  it  may  come  out  at  the  coraco- 
acromial  triangle,  as  is  now  performed  by  M.  Lisfranc,  it  is  evi- 
dent that  we  will  always  have  two  flaps  of  equal  or  unequal 
lengths,  which  might  be  approximated,  and  thus  almost  entirely 
obliterate  the  acromio-glenoidal  space.     The  same  would  occur 
from  the  circular  amputation,  which  is  preferred  by  many  Eng- 
lish surgeons ;  as  well  as  by  the  process  of  Beclard,  which  con- 
sists  of  two  incisions,   one  anterior,  the  other  posterior,  which 
commence  at  the  summit  of  the  acromion,  are  prolonged  oblique- 
ly downwards  and  forwards,  and  terminate  without  meeting,  in 
order  to  avoid  the  nerves  and  especially  the  artery,  upon  the  two 
axillary  borders.      With  respect  to  the  execution  of  these  differ- 
ent methods,  the  anatomical  arrangement  of  the  parts  exacts  for 
each  of  them  particular  precautions. 

In  that  of  Desault,  for  instance,  the  artery  should  be  previously 
compressed,  since  it  is  comprised  in  the  first  flap.  For  the  pur- 
pose of  forming  this  first  flap,  it  is  necessary  that  the  knife  should 
slide  beneath  the  humeral  head,  for  this  eminence  would  otherwise 
throw  it  too  much  inwards ;  afterwards  the  arm  must  be  drawn 
in  abduction,  in  order  to  penetrate  easily  into  the  articulation. 

In  the  two  methods  adopted  by  M.  Larrey,  and  in  one  of  those 


OP   THE    THORACIC    EXTREMITIES. 

recommended  by  M .  Dupuytren,  as  we  commence  with  the  ex- 
ternal flap,  the  artery  will  only  be  divided  in  finishing  the  opera- 
tion. 

In  Beclard's  method,  the  muscles  being  divided  down  to  the 
bone,  it  is  necessary  to  draw  upon  the  humerus  so  as  to  render  its 
head  prominent,  and  to  turn  it  in  extreme  pronation  or  supination, 
according  to  the  side.  This  rotation  is,  indeed,  indispensable,  for 
without  it  we  cannot  divide  the  capsule  to  a  sufficient  extent  upon 
the  groove  of  the  anatomical  neck  of  the  os  brachii.  This  sec- 
tion being  made,  we  can  readily  dislocate  the  humerus  forwards ; 
then  the  knife  may  be  easily  insinuated  behind  the  bone  without 
touching  the  artery,  which  is  contained  in  the  pedicle  which  sepa- 
rates the  two  flaps  ;  which  pedicle  is  divided,  after  its  base  has 
been  seized  by  an  assistant,  who  compresses  the  artery. 

In  almost  all  the  methods  connected  with  that  of  Ledran,  this 
last  step  of  the  operation,  relative  to  the  artery,  should  and  may 
be  retained,  since  we  finish  with  the  inferior  flap. 

That  of  MM.  Champesmes  and  Lisfranc  requires  a  narrow 
knife,  and  that  the  arm  should  be  kept  elevated,  in  order  to  sepa- 
rate the  articular  surfaces,  and  enlarge  the  space  which  the  instru- 
ment must  traverse.  The  edge  of  this  knife  must  be  directed 
upwards  and  forwards  towards  the  summit  of  the  acromion,  in 
order  that  it  may  glide  more  easily  between  the  glenoid  cavity 
and  the  head  of  the  humerus.  When  its  point  comes  out  behind 
the  shoulder,  we  draw  it  forwards,  first  in  the  direction  in  which 
it  is,  in  order  that  it  may  pass  out  from  the  joint ;  after  which  we 
decline  the  edge,  so  as  to  lengthen  the  external  flap  by  grazing 
the  external  aspect  of  the  os  humeri. 

That  of  M.  Lisfranc  demands  the  same  precaution  relative  to 
the  articulation  ;  but  it  is  also  necessary  to  watch  attentively  the 
place  at  which  the  instrument  is  to  make  its  escape,  in  order  to 
avoid  striking  its  point  against  the  inferior  aspect  of  the  clavicle, 
or  even  propelling  it  behind  this  bone  into  the  fossa  supra-spinata. 
It  is  also  important  that  it  should  not  be  depressed  more  than  is 
necessary,  for  it  would  pass  under  the  coracoid  process  into  the 
coraco-clavicular  triangle  and  divide  the  pectoralis  minor. 

Finally,  the  scapula  forms  a  kind  of  shield  behind  and  upon  the 
side  of  the  thorax.  It  covers  the  first  six  ribs  and  their  inter-spa- 
ces, and  corresponds  to  the  thickest  and  most  spongy  part  of  the 


*360  OF    THE    THORACIC    EXTREMITIES. 

lungs :  but,  although  it  is  enveloped  by  numerous  and  thick  muscles, 
the  stethoscope  applied,  among  other  points,  over  its  supra-spinal 
portion,  will  enable  us  to  distinguish  tolerably  well  the  state  of 
the  respiration. 

ART.  II.  Of  the  Arm. 

We  will  divide  the  arm  into  anterior  and  posterior  regions : 
but  will  examine  its  general  surface,  previous  to  entering  into 
those  details  which  concern  each  of  these  regions. 

Strictly  speaking,  the  arm  comprises  all  that  part  of  the  supe- 
rior extremity  which  is  occupied  by  the  humerus  ;  but,  as  it  re- 
gards topographical  anatomy,  the  arm  extends  from  the  shoulder 
or  axillary  region  to  two  inches  above  the  elbow  only  ;  in  fat  per- 
sons, and  especially  in  females,  the  arm  is  conoidal.  In  general, 
it  is  cylindrical,  and  more  or  less  flattened  on  its  outer  and  inner 
surfaces.  At  its  external  and  superior  part  it  presents  a  triangu- 
lar eminence,  which  is  formed  by  the  deltoid,  and  which  is  bound- 
ed, anteriorly  and  posteriorly,  by  two  furrows  which  unite  at  its 
apex,  in  order  to  form  the  deltoidal  depression  :  it  is  at  this  point 
that  issues  are  usually  inserted.  From  this  depression  another 
broad,  but  superficial,  groove  originates,  which  descends  to  the 
fold  of  the  arm  ;  it  represents  the  external  aspect  of  the  limb, 
and  is  the  place  upon  which  blisters  are  applied.  A  third  furrow 
runs  along  the  internal  aspect,  and  extends  from  the  hollow  of 
the  axilla  to  the  elbow,  where  it  joins  the  preceding.  Between 
these  two  furrows,  anteriorly,  we  observe  an  eminence,  which  is 
sometimes  very  prominent,  bulging  in  the  middle,  disappearing  in 
the  axilla  and  fold  of  the  elbow  :  this  is  the  bicipital  eminence. 
Posteriorly,  the  triceps  also  elevates  the  integuments  in  a  greater 
or  less  degree,  but  does  not  form  any  important  reliefs.  We 
suppose  the  limb  to  be  in  the  state  of  supination. 

Sect.  1.  Anterior  Brachial  Region. 

It  is  bounded,  externally,  by  the  acromio-digital  line  ;  internal- 
ly, by  the  sub-scapulo-digital  line  ;  superiorly,  by  the  hollow  of 
the  axilla,  and  inferiorly,  by  a  transverse  line  which  would  unite 


OP   THE    THORACIC    EXTREMITIES. 

the  two  preceding  two  inches  above  the  condyles  of  the  hume- 
rus. 

This  region  comprises  the  external  and  internal  bicipital  fur- 
rows, the  eminence  which  separates  them,  the  deltoidal  depress- 
ion, and  a  portion  of  the  muscular  relief  which  surmounts  it. 

CONSTITUENT   PARTS. 

i.  The  Skin. 

It  is  delicate,  white  and  very  extensible,  especially  internally, 
supplied  with  but  few  sebaceous  follicles  and  hairs,  and  entirely 
devoid  of  them  upon  the  bicipital  eminence.  In  the  internal  fur- 
row we  sometimes  distinguish  through  it  the  basilic  vein,  and  in 
the  external,  the  cephalic.  It  moves  easily  over  the  organs  be- 
neath it ;  therefore,  simple  wounds  which  have  their  seat  in  this 
region,  unless  attended  with  considerable  loss  of  substance, 
readily  unite  by  the  adhesive  inflammation. 

ii.   The  Sub-cutaneous  Layer. 

This  layer  may  acquire  a  very  great  thickness,  and  is  generally 
thicker  in  women  and  children  than  in  men ;  much  thicker,  also, 
in  the  depressions  than  upon  the  eminences.  It  is  chiefly  formed 
of  cellular  tissue,  in  the  laminae  of  which  adipose  vesicles  are  in- 
terposed, which  agglomerate  in  small  lobules  in  the  furrows,  and 
especially  below  the  deltoid  ;  it  also  envelopes  a  few  nervous  fila- 
ments externally,  where  they  are  derived  from  the  musculo- 
cutaneous :  more  numerous  internally,  where  we  find  the  inter- 
nal cutaneous  and  the  filaments  from  the  dorsal  nerves.  We  also 
observe  in  it  the  trunks  of  the  basilic  and  cephalic  veins.  All 
these  parts  are  so  disposed  that  the  veins  are  more  particularly 
enclosed  in  the  deep-seated  cellular  laminre,  whilst  the  adipose 
cells  are  developed  in  the  external  lamellae.  The  nerves  gener- 
ally lie  upon  the  same  plane  with  the  veins ;  whence  it  follows 
that  the  distance  of  the  latter  from  the  skin  is  in  proportion  to 
the  thickness  of  the  adipose  layer. 


OF    THE    THORACIC    EXTREMITIES. 


HI.  The  Aponeurosis. 

It  is  thin  and  almost  cellular  upon  the  median  line,  but  this  is 
owing  to  the  splitting  of  the  aporieurosis  upon  the  external  limits 
of  this  region  ;  then,  one  of  its  sheets  only  passes  before  the  bi- 
ceps muscle,  whilst  the  other  passes  behind  it  over  the  anterior 
face  of  the  brachialis  internus.  At  the  internal  margin  of  the 
first  of  these  muscles  the  deep  sheet  splits  in  its  turn,  and  its  two 
laminae,  in  passing  to  unite  with  the  internal  surface  of  the  super- 
ficial sheet,  furnish  a  complete  sheath  for  the  humeral  artery,  its 
collateral  veins  and  the  median  nerve.  This  sheath  is  generally 
continued  as  far  as  the  axilla. 

On  the  inner  side  of  the  arterial  sheath  there  is  another  fibrous 
canal,  which  includes  the  internal  cutaneous  nerve  and  the  basilic 
vein  ;  finally,  as  the  aponeurosis  enters  the  posterior  region  it  re- 
ceives, upon  its  internal  surface,  a  fibrous  intersection,  which  is 
very  strong  inferiorly,  is  attached  to  the  internal  ridge  of  the  hu- 
merus,  and  may  be  called  the  epitrochlo-humeral  intersection. 

The  brachial  aponeurosis  then  is  more  complicated  in  this  re- 
gion than  is  usually  admitted.  Thus,  it  is  thick  externally,  be- 
cause its  sheets  are  blended ;  in  the  internal  bicipital  groove,  it  is 
still  thicker,  because  there  all  its  laminae  are  conjoined  ;  it  forms 
a  sheath  for  the  biceps  the  sheets  of  which  are  thin,  because  they 
seem  to  have  been  distended  by  this  muscle,  which  is  of  greater 
or  less  volume  ;  a  second  sheath  for  the  artery,  the  vein  and  nerve 
which  accompany  it ;  and,  in  this  sheath,  lamellae  are  detached 
forming  secondary  envelopes  for  each  organ ;  finally,  a  third  for 
the  internal  cutaneous  nerve  and  basilic  vein,  which,  however,  is 
not  always  present,  neither  is  it  prolonged  so  far  upwards  as  the 
others.  It  is  important  to  keep  this  arrangement  in  mind  when 
about  to  tie  the  brachial  artery. 

iv.  The  Muscles. 

We  find  in  this  region  a  small  portion  of  the  deltoid  and 
roraco-brachialis,  the  greater  part  of  the  biceps  and  brachialis  in- 
ternus, the  origin  of  the  supinator  radii  longus  and  of  the  extensor 
carpi  radialis  longior  muscles. 


OP   THE    THORACIC    EXTREMITIES.  263 

(  a )  The  Deltoid  here  adheres  very  firmly  to  the  bone,  so  that 
no  fluid  can  collect  beneath  it ;  its  anterior  border  is  enveloped 
by  the  aponeurosis,  which  is  also  very  strong  where  it  abandons 
it  in  order  to  enter  into  the  axilla. 

(b)  The  termination  of  the  coraco-brachialis  is  much  more 
posterior ;  it  is  between  it  and  the  preceding  muscle  that  the  two 
portions  of  the  biceps  ascend  to  the  shoulder. 

( c )  The  whole  of  the  fleshy  belly  of  the  biceps  is  observed  at  the 
anterior  part  of  the  arm  ;  its  internal  margin  serves  to  guide  us  to 
the  vessels ;  superiorly  and  externally,  it  is  covered  by  the  del- 
toid ;  it  lies  at  first  upon  the  humerus  and  the  tendons  of  the 
coraco-brachialis,  teres    major  and  latissimus  dorsi,  afterwards 
upon  the  brachialis  internus.     Further,  it  is  free  under  the  skin  in 
its  aponeurotic  sheath ;  so  that,  in  amputations,  we  must  expect  it 
to  retract  very  much,  especially  as  we  generally  divide  it  very  far 
from  its  points  of  attachment.     In  order  to  render  it  most  promi- 
nent it  is  necessary  to  extend  the  fore-arm :  in  this  position,  if  the 
limb  is  fixed,  and  the  muscle  contracts,  it  tends  to  flex  the  hu- 
merus forwards.     Consequently,  in  fractures  of  the  arm,  it  may 
displace  the  fragments,  in  the  first  place  according  to  their  direc- 
tion, and  afterwards  according  to  their  length.     It  is  for  this  rea- 
son that  the  fore-arm  should  be  retained  in  a  flexed  position  during 
the  cure  of  these  diseases. 

( d )  The  Brachialis  Internus  is  in  a  great  measure  concealed 
by  the  biceps,  which  it  passes  a  little  beyond,  however,  on  each 
side ;  so  that  the  artery  rests  upon   its  inner  portion,  etc.     It 
originates  from  the  whole  of  the  anterior  surface  of  the  os  brachii, 
and  also  from  the  fore-part  of  the  fibrous  intersections  attached  to 
the  borders  of  this  bone ;  superiorly,  it  is  thinner  and  bifurcates 
so  as  to  resemble  the  letter  V,  in  order  to  embrace  the  apex  of 
the  deltoid.     It  is  between  the  insertion  of  these  two  muscles,  the 
biceps  which  is  internal,  and  the  triceps  which  is  external,  that  we 
find  the  deltoidal  fossette,  which  is  also  filled  by  cellular  tissue  and 
fat.     This  fossette  then  is  so  disposed,  that  the  muscles  which 
circumscribe  it  are  not  susceptible  of  moving  or  sliding  over  one 
another  at  this  point ;  and  it  is  for  this  reason,  as  well  as  on  ac- 
count of  the  cellular  tissue  here  met  with,  that  we  apply  caustics 
upon  this  excavation. 

As  this  muscle  adheres  to  all  the  points  of  the  bone  which  it 


264  OF   THE    THORACIC4    EXTREMITIES. 

covers,  and  as  its  moveable  point  is  situated  upon  the  ulna,  it  fol- 
lows that,  in  fractures  of  the  inferior  half  of  the  humerus,  it  oppo- 
ses rather  than  favours  the  displacement.  From  this  disposition 
also,  the  brachialis  internus  cannot  retract  in  amputations ;  there- 
fore the  biceps  should  be  divided  first,  in  these  operations,  in  order 
that  the  knife  may  afterwards  be  carried  as  high  as  this  muscle 
has  retracted. 

(  e  )  There  is  only  a  small  portion  of  tfie  supinator  radii  longus 
in  the  anterior  brachial  region :  it  appertains  to  the  elbow  and 
fore-arm ;  it  was  necessary  to  note  here,  however,  that  it  origin- 
ates from  the  fibrous  intersection  on  the  inner  side  of  the  pre- 
ceding. 

v.  The  Arteries. 

(a)  The  Brachial  Artery.  The  relations  of  this  vessel,  from 
the  tendon  of  the  latissimus  dorsi  to  its  entrance  into  the  region 
of  the  elbow,  are  the  following :  Enveloped  in  its  aponeurotic 
sheath,  it  is  always  accompanied  by  the  median  nerve  and  the 
humeral  vein  or  veins,  so  that  we  cannot  attack  one  of  these  or- 
gans without  running  some  risk  of  injuring  the  others ;  superiorly, 
the  nerve  is  on  the  outer  side  of,  or  anterior  to,  the  artery ;  lower 
down,  the  former  crosses  the  latter  very  obliquely,  passing  almost 
always  over  its  anterior  surface,  and  sometimes  only  behind  it ; 
so  that,  inferiorly,  it  is  almost  uniformly  upon  its  inner  side.  The 
cellular  process  which  unites  them  in  the  interior  of  their  com- 
mon canal,  is  sometimes  so  dense  that  it  affords  a  certain  resist- 
ance to  the  needle  with  which  we  attempt  to  separate  them. 
This  nerve  can  scarcely  be  confounded  with  the  arterial  trunk ; 
its  volume,  form,  colour,  consistency,  and  superficial  position,  do 
not  permit  us  to  commit  this  error :  the  vein,  or  rather  the  veins, 
for  there  are  almost  always  two,  are  still  more  immediately 
applied  upon  this  vessel ;  so  that  in  the  order  of  super-position  it 
is  only  upon  the  third  plane.  When  there  is  only  one  vein,  it  is 
on  the  inner  side ;  if  two,  they  are  situated  on  each  side,  and 
sometimes  they  send,  reciprocally,  branches  of  communication 
which  pass  over  the  anterior  face  of  the  artery :  it  is  then  diffi- 
cult to  separate  and  exclude  them,  in  the  ligature  of  this  artery. 

If  we  consider  it  as  divested  of  its  sheath,  of  the  median  nerve 


OP  THE    THORACIC    EXTREMITIES.  265 

and  collateral  veins,  the  brachial  artery  rests  posteriorly,  from 
nbove  downwards,  upon  the  humerus,  the  tendon  of  the  coraco- 
brachialis  muscle,  the  fore-part  of  the  internal  portion  of  the 
triceps,  and  the  brachialis  internus ;  consequently,  we  may  easily 
compress  it  against  the  bone  in  its  superior  third.  Externally,  it 
is  still  coasted  by  the  coraco-brachialis,  then  by  the  biceps  ;  inter- 
nally, it  is  separated  from  the  triceps  and  the  (intermuscular)  lig. 
aments,  first  by  the  radial  nerve  and  internal  collateral  artery, 
afterwards  by  the  ulnar  nerve,  which  diverges  from  it  more  and 
more  in  proportion  to  its  descent;  and  lastly,  by  the  internal 
cutaneous  nerve  and  basilic  vein,  enclosed  in  their  sheath.  The 
latter  are  more  approximated  to  the  artery  above  than  below, 
and,  in  many  subjects,  the  septum  which  separates  the  two 
fibrous  canals  disappears  in  the  former  direction.  In  its  inferior 
fourth,  it  no  longer  has  any  relation  with  the  triceps ;  it  is  the 
brachialis  internus  which  then  conceals  its  internal  portion.  An- 
teriorly, and  more  or  less  internally,  it  is  covered  by  the  aponeu- 
rosis,  the  superficial  layer  and  the  skin,  throughout  its  whole  ex- 
tent ;  sometimes  also  the  belly  of  the  biceps  inclines  more  or  less 
in  this  direction ;  but,  generally,  in  subjects  of  moderate  embon- 
point, whose  muscles  are  not  very  large,  the  pulsations  of  the 
artery  may  be  easily  felt  by  applying  the  fingers  along  the  internal 
bicipital  furrow.  Hence  it  follows  that  this  artery  may  be  surely 
discovered  by  making  an  incision  upon  the  furrow  just  men- 
tioned, in  the  direction  of  a  line  drawn  from  the  hollow  of  the 
axilla,  one  inch  before  its  posterior  margin,  along  the  inner  side 
of  the  biceps,  to  the  bend  of  the  elbow.  The  skin  being  cau- 
tiously divided,  on  account  of  its  tenuity,  we  perceive  the  cellular 
or  superficial  layer;  this  being  incised,  the  edge  of  the  knife 
sometimes  comes  in  contact  with  some  small  veins,  which  it  is 
convenient  to  avoid,  and  even  the  basilic  vein,  if  it  has  not  yet 
passed  through  the  aponeurosis,  which  next  comes  in  view :  this 
last  layer  will  present  only  one  thick  sheet,  which  will  be  easily 
traversed,  if  we  have  fallen  directly  upon  the  arterial  sheath ;  but 
if,  on  the  contrary,  we  have  kept  too  close  to  the  biceps,  we  will 
have  to  divide,  first,  the  delicate  expansion  which  covers  this 
muscle,  and  afterwards  the  external  part  of  the  envelope  of  the 
artery. 

Then  will  be  exposed  the  median  nerve  and  the  vessels ;  per* 

34 


'JOG  OF  THE    THORACIC    EXTREMITIES. 

haps  also  the  internal  superficial  vein  and  nerve  ;  but,  in  order  to 
avoid  mistaking  the  precise  seat  of  the  arterial  trunk,  it  is  suffi- 
cient to  recollect  that  the  median  nerve  is  the  first  cord  which  we 
meet  with  in  departing  from  the  biceps  muscle. 

The  Arteria  humeralis  profunda  superior,  or  the.  great  col- 
fciteral,  generally  arises  from  the  brachial  a  little  below  the  teres 
major ;  sometimes,  also,  it  is  derived  from  the  subscapulary,  cir- 
cumflexi,  etc.,  arteries.  In  either  case,  it  immediately  directs  its 
course  towards  the  interstice  of  the  internal  and  middle  heads  of 
the  triceps  muscle,  in  order  to  enter  the  posterior  region.  Its 
volume  is  sometimes  very  considerable,  and  it  is  the  principal 
branch  for  re-establishing  the  circulation  after  the  ligature  of  the 
humeral.  The  application  of  this  ligature  should  not,  if  possible, 
be  made  too  near  the  arteria  anastomotica  profunda  superior ; 
for  then  the  blood  cannot  readily  stagnate  above  the  obliterated 
point,  which  will  render  the  formation  of  the  coagulum  difficult. 

(  c  )  The  middle  anastomotic  (anastomotica  magna)  is  seen 
about  the  middle  of  the  arm,  and  passes  for  some  distance  upon 
the  brachialis  internus  previous  to  perforating  the  intermuscular 
ligament,  in  order  to  get  to  the  posterior  part  of  the  arm.  It 
follows  the  ulnar  nerve  in  the  same  manner  that  the  preceding 
accompanies  the  radial.  Generally  of  small  volume,  it  is  some- 
times very  large,  and  may  equal  the  size  of  the  brachial.  We 
must  not  forget  the  possibility  of  such  a  disposition  when  we 
perform  any  operation  upon  the  internal  part  of  the  arm,  in  gen- 
eral, and  upon  the  humeral  artery  in  particular.  It  is  also  an 
additional  reason  for  inducing  surgeons  to  place  the  ligature 
rather  near  the  aneurism al  tumour  than  at  a  distance  from  it, 
when  we  operate  upon  this  portion  of  the  limb ;  and  it  should 
likewise  be  recollected  in  amputation,  in  order  that  it  may  be 
secured. 

(  d  )  The  Nutrient  Artery  of  the  bone  (Nutritia  magna  7m- 
meri)  is  found  towards  the  termination  of  the  coraco-brachialis  ; 
it  generally  traverses  the  tendon  of  this  muscle,  slides  obliquely 
upon  the  humerus,  and  penetrates  its  osseous  canal.  It  should  be 
noticed,  because  when  its  volume  is  increased,  as  it  is  in  most, 
cases  requiring  amputation,  if  the  section  of  the  bone  is  made 
near  the  deltoidal  impression,  a  considerable  flow  of  blood  may 
he  the  consequence.  In  fractures  of  this  part  of  the  bone  if 


OF   THE    THORACIC    EXTREMITIES.  '267 

may  be  lacerated,  and  give  rise  to  extensive  ecchymoses  which  it 
would  be  difficult  to  attribute  to  a  wound  of  the  veins. 

It  is  not  uncommon  to  see  the  origin  of  the  inferior  or  internal 
collateral  at  the  lower  fourth  of  the  anterior  brachial  region ;  but 
as  it  is  still  more  frequently  found  in  the  region  of  the  elbow,  we 
will  there  examine  it.  As  to  the  other  branches  given  off  by  the 
humeral,  they  are  too 'small  and  irregular  to  arrest  the  surgeon's 
attention. 

The  Brachial  artery  is  sometimes  double  from  its  origin ;  at 
other  times,  from  a  more  or  less  elevated  point  of  the  extremity 
only ;  then  the  two  trunks  may  be  of  equal  volume :  more  fre- 
quently one  is  smaller  than  the  other ;  in  which  case  the  external 
is  the  largest :  sometimes,  but  less  frequently,  it  is  the  internal. 
Be  it  as  it  may,  this  anomaly  might  give  rise  to  serious  errors,  if 
we  were  obliged  to  tie  the  humeral  artery  where  it  existed. 

vi.  The  Veins. 

They  are  superficial  and  deep-seated.  The  former  are  the 
Cephalic  and  Basilic. 

(  a  )  The  Cephalic  ascends  parallel  to  the  biceps  on  the  fore 
part  of  the  external  furrow  of  the  arm ;  it  gradually  inclines  in- 
wards, so  as  to  enter  the  interstice  which  separates  the  deltoid 
from  the  pectoralis  major  (coraco-deltoidal  groove) ;  then  it  con- 
tinues in  the  anterior  region  of  the  shoulder  throughout  the  whole 
extent  of  this  groove.  The  cephalic  vein  is  situated  external  to 
the  aponeurosis,  enveloped  in  the  deep  laminae  of  the  subcutane- 
ous layer ;  in  the  coraco-deltoidal  groove,  on  the  contrary,  it  is 
interposed  in  the  laminae  of  the  fascia  brachialis,  which,  in  this 
place,  is  nothing  more  than  cellular  tissue  more  or  less  condensed. 
However,  it  follows  from  this  difference  in  the  relations  of  this 
vein  with  the  aponeurosis,  that  it  is  always  somewhat  deeply 
seated  superiorly ;  whilst,  below  the  deltoid,  it  is  so  superficial 
that  we  see  it  through  the  skin,  even  in  persons  who  are  not 
emaciated.  It  seldom  becomes  varicose ;  nevertheless,  some 
cases  of  this  nature  are  recorded.*  Strictly  speaking,  it  is  pos- 
sible to  open  it  with  a  lancet,  throughout  its  whole  course,  with- 

*  Briquet,  th£se  1824.  Archives,  1925. 


268  01'    THE    THORACIC    EXTREMITIES. 

out  danger.  Interiorly,  it  is  only  accompanied  by  some  filaments 
of  the  external  cutaneous  nerve. 

(  b  )  The  Basilic  is  situated  in  the  middle  of  the  internal  bicip- 
ital  gutter.  It  is  at  first  enveloped  in  the  laminae  of  the  fascia 
superficialis,  but,  like  the  cephalic,  afterwards  abandons  this 
layer,  sometimes  immediately  above  the  elbow,  at  other  times 
only  when  it  is  about  entering  the  axilla  in  order  to  traverse 
the  brachial  aponeurosis,  and  empty  into  the  deep-seated  veins. 
Whilst  it  is  cutaneous,  it  is  surrounded  by  numerous  filaments  of 
the  internal  superficial  nerve,  and  in  the  aponeurosis,  we  have 
already  stated  that  it  runs  by  the  side  of  the  trunk  of  this  nerve, 
in  the  same  manner  that  the  humeral  artery  does  by  the  median, 
and  that  it  is  included  in  a  distinct  sheath,  separated  by  a  par- 
tition from  that  of  the  artery :  it  is  then,  so  to  say,  both  super- 
ficial and  deep-seated.  Hence,  when  it  inflames,  it  may  give  rise 
to  a  simple  erysipelas  in  the  lower  part  of  the  arm,  whilst  in  its 
superior  portion,  it  may  occasion  a  general  tumefaction.  For 
the  same  reason  it  may  determine  the  formation  of  abscesses 
between  the  aponeurosis  and  the  integuments,  and  also  give  rise 
to  them  between  the  muscles ;  whilst  the  inflamed  cephalic  vein 
can  only  produce  similar  consequences  in  the  subcutaneous 
layer. 

The  deep-seated  veins  were  pointed  out  when  speaking  of  the 
artery ;  we  will  only  add  here  that,  when  we  wish  to  obliterate  the 
latter,  we  should  carefully  avoid  comprising  them  in  the  noose, 
because  their  ligature  is  generally  dangerous,  from  the  phlebitis 
which  it  produces. 

vir.  The  Lymphatics. 

The  superficial  lymphatics  abound  in  the  bicipital  furrows, 
where  they  are  clustered  around  the  cephalic  and  basilic  veins. 
The  latter  in  particular  is  accompanied  by  a  very  complicated 
lymphatic  plexus,  which  remains  in  the  superficial  cellular  layer 
until  it  reaches  the  cavity  of  the  axilla.  It  is  on  account  of  the 
great  abundance  of  absorbent  vessels  and  cellular  tissue  which 
we  find  in  the  internal  bicipital  gutter,  and  even  throughout  the 
whole  internal  surface  of  the  arm ;  it  is  because  the  skin  is  more 
delicate  and  sensible  here  than  elsewhere,  that  we  are  advised  to 


OP   THE    THORACIC    EXTREMITIES.  '260 

apply  medicinal  substances  upon  this  surface,  with  the  view  of 
Introducing  them  into  the  general  circulation. 

The  deep-seated  lymphatic  vessels  form  two  or  three  bundles 
around  the  artery  and  veins :  they  are  interrupted  from  the  elbow 
to  the  axilla  by  glands,  which  seldom  exceed  four  or  five  in  num- 
ber ;  very  frequently  there  are  none,  and  when  they  do  exist, 
they  are  naturally  very  small.  However  this  may  be,  it  is  neces- 
sary to  recollect  their  exact  position  ;  for,  if  they  enlarge  gradu- 
ally, they  may  contract  adhesions  with  the  artery,  and  impose 
upon  us  for  aneurisms.  We  have  twice  met  with  a  single  lym- 
phatic gland  in  the  upper  part  of  the  deltoidal  fossette.  In  both 
cases  it  was  of  the  size  of  a  large  lentil,  and  the  vessels  passed 
towards  it  in  a  convergent  direction :  it  was  external  to  the  apo- 
neurosis. 

vm.  The  Nerves. 

(a)  The  relations  of  the  median  were  pointed  out  above, 
when  speaking  of  the  artery. 

( b  )  The  musculo  cutaneus,  or  external  cutaneous,  instead  of 
perforating  the  coraco-brachialis  muscle,  sometimes  remains  for 
a  considerable  time  upon  the  external  side  of  the  artery ;  and  in 
this  case,  if  we  were  not  attentive,  it  might  be  mistaken  for  the 
median  nerve.  Be  this  as  it  may,  in  enters  into  the  sheath  of 
the  biceps,  and  is  soon  found  on  the  outer  side  of  this  muscle 
opposite  to  the  cephalic  vein,  from  which,  however,  it  is  separa- 
ted by  the  aponeurosis  as  far  as  the  inferior  part  of  the  region. 

(  c  )  The  Internal  Cutaneous.  Next  to  the  median,  this  lies 
nearest  to  the  artery.  Situated  upon  a  plane  a  little  more  ante- 
rior, it  follows  the  external  border  of  the  basilic  vein,  runs  with 
it  into  its  canal,  and  escapes,  at  the  same  time  with  it,  from  the 
aponeurosis.  In  its  course  it  gives  off  numerous  filaments  to  the 
superficial  layer.  It  is  sometimes  of  considerable  volume,  so 
that  at  the  first  glance  it  might  be  mistaken  for  the  median  ;  but 
this  error  would  soon  be  corrected  by  referring  to  the  biceps 
muscle. 

(  d )  The  Ulnar  Nerve  is  placed  upon  the  internal  side  of  the 
brachial  artery  before  the  triceps  muscle,  by  which  it  is  enveloped 
almost  from  its  commencement,  and  which  it  traverses  about  the 


270  OF    THE    THORACIC    EXTREMITIES. 

middle  of  the  arm,  in  order  to  get  into  the  posterior  region,  be- 
behind  the  epicondylo-humeral  intersection  (intermuscular  liga- 
ment). 

( e )  The  Radial  is  still  more  posterior  and  more  external.  It 
follows  the  direction  of  the  great  collateral  artery  of  the  arm, 
that  is  to  say,  it  turns  round  the  humerus  between  the  heads  of 
the  triceps,  abandoning  almost  immediately  the  region  in  which 
it  originates.  It  is  most  frequently  the  largest  of  all.  The  vol- 
ume of  the  nerves  of  the  arm  would  be  pretty  accurately  gradu- 
ated in  the  following  order :  1st,  The  Radial;  2d,  the  Median  ; 
3d,  the  Ulnar ;  4th,  the  Musculo  Cutaneus ;  5th,  the  Internal 
Cutaneous. 

We  also  have  here  the  nervous  filaments  which  come  from  the 
intercostal  nerves,  and  which  are  entirely  lost  in  the  superficial 
layer,  upon  the  internal  surface  of  the  arm.  These  twigs  estab- 
lish a  certain  sympathetic  relation  between  the  arm  and  the  or- 
gans contained  in  the  thorax ;  a  relation  to  wrhich  many  physi- 
cians have  ascribed  considerable  importance,  when  they  have 
endeavoured  to  explain  the  revulsive  action  of  blisters  applied 
upon  the  superior  extremity  in  diseases  of  the  thorax. 

ix.  The  Skeleton. 

It  is  formed  by  the  anterior  part  of  the  humerus,  which  is 
slightly  curved  in  this  direction,  rounded  and  prominent  above, 
and  which  gradually  grows  broader  as  it  descends.  It  is  between 
the  point  of  insertion  of  the  latissimus  dorsi,  coraco-brachialis  and 
pectoralis  major,  that  this  bone  may  serve  for  the  compression 
of  the  artery,  as  it  is  there  prevented  from  rolling  under  the  fin- 
gers by  these  muscles.  To  its  anterior  surface  the  coraco-bra- 
chialis, deltoid  and  brachialis  internus  are  attached.  But  we  will 
examine  the  different  peculiarities  which  concern  this  bone  with 
more  advantage,  when  we  come  to  speak  of  the  posterior  bra- 
chial  region. 

Sect.  2.  Posterior  Brachicd  Region. 

This  region  is  much  less  complicated  than  the  preceding,  and 
„  of  minor  importance  in  surgery .     In  its  superior  portion  it  pre- 


OF   THE    THORACIC    EXTREMITIES.  271 

sents  a  part  of  the  deltoidal  eminence  and  of  the  posterior  groove 
of  the  same  name  :  as  for  the  rest,  it  is  rounded  and  convex. 


CONSTITUENT   PARTS. 

i.  The  Skin. 

This  layer  is  compact,  thick,  rugous,  and  much  less  extensible 
than  on  the  fore  part  of  the  arm ;  it  is  also  darker,  and  contains 
many  piliferous  bulbs  and  a  great  quantity  of  sebaceous  follicles. 
It  is  these  bulbs  and  follicles  which  sometimes  give  to  the  skin 
that  irregular  and  rough  appearance,  vulgarly  called  "goose-flesh" 
which  manifests  itself  in  consequence  of  some  violent  mental 
impression  or  sudden  exposure  to  cold.  Boils  frequently  occur 
in  it. 

ii.  T/ie  Subcutaneous  Layer. 

It  is  less  complicated  and  always  much  thinner  than  anteriorly ; 
includes  only  a  small  number  of  vascular  and  nervous  twigs, 
and  but  few  adipose  vesicles.  Consequently,  the  cellular  is  al- 
most the  only  tissue  which  exists  in  it ;  it  is  lamellated,  and  its. 
lamellae,  more  or  less  compact,  sometimes  form  a  complete  fas- 
cia superficialis.  From  the  compact  texture  of  the  skin,  and  the 
slight  adhesion  of  the  cellular  layer,  pus  burrows  under  these  parts 
with  the  greatest  facility  and  with  difficulty  makes  its  escape 
externally :  hence  we  should  open  abscesses,  occurring  in  this 
region,  at  an  early  period. 

in.  The  Aponeurosis. 

This  is  generally  thicker  than  upon  the  fore  part  of  the  biceps, 
but  thinner  than  in  the  brachial  gutters.  Its  fibres  are  principally 
transversal.  It  is  continuous,  superiorly,  with  the  tendon  of  the 
latissimus  dorsi,  which  may  be  considered  as  its  tensor ;  inferior- 
ly,  where  it  passes  upon  the  anterior  region,  it  receives  the  fibrous 
intersection  which  originates  from  each  side  of  the  humerus,  and 
it  is  then  that  these  intersections  form  two  species  of  ligament. 
Elsewhere,  it  consists  of  one  sheet  only,  except  as  it  approaches 


272  OP   THE    THORACIC    EXTREMITIES. 


the  internal  intersection,  where  its  laminae  split  in  order  to  en- 
,  velope  the  ulnar  nerve. 

iv.  The  Muscles. 

Properly  speaking,  this  region  includes  the  Triceps  only.  That 
portion  of  the  deltoid  which  is  observed  in  the  upper  part,  can 
give  rise  to  no  further  remarks  than  have  been  made  in  the  pre- 
ceding regions.  It  is  necessary  to  note  that,  superiorly,  the  fibres 
of  the  triceps  are  nearly  parallel  to  the  direction  of  the  bone ; 
whilst  inferiorly  they  run  obliquely  from  the  median  line  towards 
the  sides :  they  are  connected  to  the  aponeurosis  by  means  of 
a  very  supple  lamellated  cellular  tissue,  which  easily  inflames 
and  sometimes  gives  rise  to  severe  symptoms,  owing  to  the 
resistance  which  the  aponeurosis  opposes  to  the  accumulation  of 
the  fluid.  Its  anterior  surface  is  attached  to  almost  the  whole 
length  of  the  bone,  and  this  is  a  very  important  circumstance  to 
note,  both  in  relation  to  amputations  and  fractures.  When  we 
amputate  the  arm,  for  instance,  if  we  wish  to  make  two  flaps, 
after  the  manner  of  Vermale  or  Ravaton,  the  triceps  will  accom- 
modate itself  to  this  method ;  but  as  the  biceps  is  entirely  free 
on  the  fore  part  of  the  arm,  it  will  retract  too  far,  and  will  form 
too  round  a  mass  for  the  flap  to  be  sufficiently  regular  on  this 
side. 

If  we  operate  by  the  circular  method,  as  the  biceps  alone  is 
capable  of  retraction,  it  is  useless,  with  the  view  of  preventing 
the  projection  of  the  bone,  to  dissect  up  the  skin,  as  was  done  by 
Petit  and  Cheselden.  It  is  sufficient  for  the  assistant  to  draw  up 
the  skin  firmly,  whilst  we  cut  it  and  divide  the  cellular  bridles 
which  retain  it  upon  the  triceps,  in  order  that  this  muscle  may  be 
incised  sufficiently  high  up. 

In  fractures  which  occur  lower  down  than  the  insertion  of  the 
deltoid,  as  the  triceps  is  attached  to  the  two  fragments,  which  are 
enveloped  by  it,  it  is  incapable  of  producing  displacement ;  on 
the  contrary,  like  the  brachialis  internus,  it  always  tends  to 
maintain  them  in  contact ;  therefore  these  kinds  of  fractures  are 
rarely  followed  by  much  over-lapping,  unless  they  are  very 
oblique,  or  the  fracturing  cause  has  continued  to  act  after  the 
fracture  of  the  bone. 


OF   THE    THORACIC    EXTREMITIES.  273 


v.  The  Arteries. 

These  vascular  branches  are*  few  in  number,  and  are  all  de- 
rived from  the  humeral  artery ;  they  only  merit  our  attention  on 
account  of  the  anastomoses  which  establish  a  communication 
between  them  and  the  collateral  arteries  of  the  fore-arm,  and 
which  re-establish  the  circulation  after  the  obliteration  of  the 
brachial  artery.  We  find  in  this  region  the  great  collateral  (pro- 
funda)  which  turns  round  the  humerus,  first  between  the  internal 
and  scapulary  bundles  (short  and  long  portions)  of  the  triceps, 
then  before  the  latter,  afterwards  upon  the  external  (longer)  por- 
tion, in  order  to  terminate  in  the  vicinity  of  the  epitrochlea  (inter- 
nal condyle).  All  the  ramuscules  which  it  gives  off  in  this  track 
are  lost  in  the  triceps.  It  is  seldom  that  any  of  them  are  so 
large  as  to  require  a  ligature  after  amputation :  but  the  collateral 
must  be  carefully  tied.  In  this  case  we  should  not  forget  that 
it  is  accompanied  by  the  radial  nerve,  in  order  to  exclude  this 
cord  from  the  ligature. 

The  other  branches  are  derived  from  the  arteria  profunda  me- 
dia and  the  internal  collateral  (anastomotica  magna)  ;  they  inos- 
culate a  great  number  of  times  with  those  just  mentioned,  and  are 
too  small  to  require  any  particular  precautions  in  operations ;  so 
that  if  we  amputate  the  arm  some  inches  above  the  elbow,  it  will 
scarcely  ever  be  necessary  to  tie  more  than  the  brachial  artery 
and  the  great  anastomotic ;  if,  on  the  contrary,  the  operation  was 
performed  in  the  middle  of  the  limb,  haemorrhage  might  take 
place  from  the  brachial,  profunda  superior  (external  collateral) 
and  media,  and  even  from  the  arteria  nutritia  of  the  bone ;  and 
from  this  circumstance  it  is  necessary  to  recollect  the  exact  posi- 
tion of  these  arteries* 

vi.  The  Veins. 

They  have  the  same  disposition  with  the  arteries,  are  not  su- 
perficial, nor  susceptible  of  any  particular  surgical  applications, 

35 


274  OF    THE    THORACIC    EXTREMITIES. 


vn.  The  Lymphatics. 

Almost  all  of  them  pass  into  the  internal  bicipital  furrow,  are 
few  in  number,  and,  so  far  as  is  known,  destitute  of  glands  in  this 
region. 

vni.  The  Ncwes. 

(a)  The  superficial  filaments  are  small  and  few  in  number ; 
they  appertain  almost  entirely  to  the  internal  cutaneous  and  dor- 
sal branches :  externally,  in  fact,  scarcely  any  of  them  are  fur- 
nished by  the  external  cutaneous  nerve. 

(  b  )  The  Ulnar  (Cubital)  is  the  most  remarkable  ;  it  only  en- 
ters into  this  region  towards  the  inferior  third  of  the  arm.  It  then 
runs  between  the  brachialis  internus  and  triceps,  and  the  aponeu- 
rosis  furnishes  it  with  a  process  which  is  converted  into  a  canal  by 
the  internal  fibrous  intersection  ;  after  which  it  takes  its  course, 
surrounded  by  this  sheath,  along  the  inner  border  of  the  arm,  and 
in  so  superficial  a  situation  that  it  is  very  much  exposed  to  in- 
jury. 

(  c  )  The  Radial,  which  is  likewise  very  large,  gives  several 
branches  to  the  different  portions  of  the  triceps,  and  exactly  fol- 
lows the  course  and  distribution  of  the  deep  humeral  artery  until 
it  arrives  opposite  to  the  origin  of  the  supinator  longus,  where  it 
traverses  the  external  fibrous  intersection,  in  order  to  penetrate 
into  the  anterior  region  between  this  muscle  and  the  brachialis 
internus.  This  nerve,  resting  immediately  upon  the  humerus,  is 
more  exposed  than  all  the  others  to  be  stretched  or  torn  in  frac- 
tures which  take  place  below  the  neck  of  the  bone. 

ix.  The  Skeleton. 

This  is  formed  by  the  body  of  the  os  brachii,  which  is  the  nar- 
rowest part  of  the  bone,  and  consequently  is  more  disposed  to 
yield  to  the  action  of  indirect  causes  of  fractures  ;  and  as  blows, 
falls,  etc.,  have  a  greater  hold  on  it  than  upon  the  extremities  of 
the  bone,  it  follows  that  its  fractures  must  be  very  frequent. 

In  consequence  of  the  muscular  insertions,  these  solutions  of 


OF   THE    THORACIC    EXTREMITIES-.  275 

continuity  may  be  arranged  in  three  orders : — 1st,  In  those  which 
take  place  between  the  deltoid  and  teres  major,  the  parts  are  so 
disposed  that  the  inferior  fragment  is  drawn  forwards  and  out- 
wards by  the  biceps  and  deltoid,  and  downwards  by  the  long  por- 
tion of  the  triceps  ;  whilst  the  coraco-brachialis,  latissimus  dorsi, 
teres  major  and  pectoralis  major,  tend  to  draw  the  superior  frag- 
ment inwards.  It  is  in  this  species  of  fracture  that  the  displace- 
ment may  be  carried  to  the  greatest  extent,  and  it  seldom  fails  to 
take  place. 

When  the  fracture  occurs  towards  the  deltoidal  depression, 
the  superior  fragment  is  abandoned  to  the  deltoid  and  to  the  mus- 
cle of  the  shoulder,  which  draw  it  outwards  and  forwards.  The 
inferior  end  remains  under  the  control  of  the  brachialis  internus, 
which  then  takes  its  fixed  point  from  the  ulna.  The  biceps  and 
the  long  portion  of  the  triceps,  in  this  case,  counteract  each  other. 

Finally,  in  the  third  case,  that  is  where  the  fracture  takes  place 
near  the  inferior  third  of  the  region,  the  two  fragments  are  found 
simultaneously  enveloped  by  the  brachialis  internus  and  the  tri- 
ceps :  so  that  it  is  very  rare  to  see  the  muscles  alone  produce  the 
displacement. 

ART.  III.     OF   THE    ELBOW. 

Under  this  title  we  comprehend  that  portion  of  the  superior  ex- 
tremity which  is  circumscribed,  superiorly,  by  the  circular  line 
which  forms  the  inferior  boundary  of  the  arm,  and  inferiorly  by 
another  circular  line  drawn  three  inches  below  the  humeral  con- 
dyles.  This  part,  like  the  arm,  will  be  divided  into  anterior  and 
posterior  regions. 

Sect.  1.  Anterior  Region  of  the  Elbow;  or  Fold  of  the  Arm. 
(Vide  Plate  6.) 

This  region  is  very  important  with  respect  to  venesection,  and 
aneurisms  which  frequently  have  their  seat  in  it.  Its  surface  pre- 
sents, superiorly,  the  termination  of  the  bicipital  prominence ;  ex- 
ternally and  internally,  two  other  muscular  eminences,  which  con- 
verge towards  one  another  and  at  length  become  conjoined  at 
their  entrance  into  the  anti-brachial  region.  These  last  are  sepa- 


276  OF   THE   THORACIC    EXTREMITIES. 

rated,  superiorly,  by  the  first  prominence,  and  inferiorly  by  a  tri- 
angular depression  of  greater  or  less  depth.  This  excavation, 
which  is  prolonged  upon  the  fore-arm,  forming  a  simple  groove, 
results  from  the  reunion  of  the  two  bicipital  gutters,  which  are 
blended  between  the  three  eminences  just  mentioned. 

CONSTITUENT  PARTS. 

i.  The  Skin. 

It  is  delicate  and  white,  especially  in  the  gutters  and  the  medi- 
an excavation,  as  well  as  upon  the  bicipital  prominence  ;  it  is  also 
covered  with  some  hairs  upon  the  lateral  eminences,  where  it  con- 
tains more  sebaceous  follicles  than  in  the  other  points  of  the  re- 
gion. As  it  receives  a  great  number  of  nervous  filaments  and 
blood  vessels,  it  readily  inflames,  and  frequently  becomes  the  seat 
of  small  phlegmons,  or  of  erysipelas. 

ii.  The  Subcutaneous  Layer. 

This  layer  is,  if  I  may  so  say,  composed  of  two  sheets :  one, 
deep-seated,  a  species  of  aponeurosis,  in  the  lamina?  of  which  are 
the  subcutaneous  nerves  and  vessels ;  the  other,  superficial,  con- 
stituted principally  of  adipose  cells,  and  variable  in  thickness.  In 
emaciated  individuals,  the  latter  sheet  scarcely  exists,  whilst  the 
other  is  then  thicker  and  more  firmly  adherent  to  the  skin.  This 
deep-seated  sheet,  thicker  in  the  gutters  than  upon  the  eminences, 
penetrates,  in  accompanying  the  deep  median  vein,  between  the 
pronator  radii  teres  and  the  supinator  longus,  in  order  to  become 
continuous  with  the  intermuscular  cellular  plates  and  the  cellular 
tissue  surrounding  the  articulation. 

It  is  in  the  subcutaneous  layer  that  phlegmonous  erysipelas  has 
its  seat ;  and  hence  we  may  conceive  with  what  facility  the  in- 
flammation and  pus  may  traverse  into  the  neighbouring  regions. 

in.  The  Aponeurosis. 

In  thin  adults,  whose  aponeuroses  are  strong  and  well  delineat- 
ed, the  following  is  the  natural  disposition  which  that  of  the  fold 


OF   THE    THORACIC    EXTREMITIES.  277 

of  the  elbow  presents  :  it  is  merely  a  continuation  of  that  of  the 
arm  ;  but  as  it  is  excessively  complicated,  it  requires  to  be  exam- 
ined in  its  several  points  separately.  On  the  outer  side  of  the 
biceps,  the  superficial  sheet,  which  covered  the  inferior  portion  of 
this  muscle,  passes  upon  the  anterior  face  of  the  external  muscu- 
lar eminence  ;  and  where  it  dips,  the  deep-seated  sheet  is  also  ap- 
plied to  it,  down  into  the  external  furrow.  There  the  aponeurosis  is 
thicker,  and  its  laminae  soon  separate  in  order  to  envelope  the  su- 
pinator  longus  muscle  ;  lower  down,  the  deep-seated  sheet  only 
persists  in  the  median  excavation,  where  it  is  found  strengthened 
by  a  lamina  of  greater  or  less  thickness,  which  is  detached  from 
the  tendon  of  the  brachialis  internus.  As  it  descends,  this  deep- 
seated  sheet  rises  again,  so  that  it  passes  between  the  radiales  and 
supinator  longus,  on  the  one  part,  and,  on  the  other,  expands  upon 
the  anterior  face  of  the  latter  muscle,  becoming  blended  with  the 
superficial  sheet ;  finally,  at  the  inferior  part  of  the  region,  these 
sheets  again  approximate,  and  it  is  between  them  that  we  meet 
with  the  radial  artery,  vein  and  nerve. 

On  the  inner  side  of  the  biceps,  the  superficial  sheet,  stronger 
than  on  the  outer  side,  spreads  obliquely  over  the  internal  mus- 
cular eminence.  The  deep-seated  sheet,  which  is  still  thicker, 
is  also  derived  from  the  internal  and  inferior  part  of  the  brachialis 
internus  :  as  it  ascends,  its  fibres  are  directed  obliquely  inwards 
and  upwards ;  it  splits  occasionally  in  order  to  envelope  the  basilic 
vein,  which  also  sometimes  passes  between  this  and  the  super- 
ficial sheet.  As  it  descends,  it  likewise  unfolds,  and  one  of  its 
laminae  rises  over  the  fore  part  of  the  pronator  radii  teres,  where 
it  blends  itself  with  the  superficial  sheet,  whilst  the  other  dips 
down  between  the  muscles.  The  bandelet  which  is  detached 
from  the  external  margin  of  the  tendon  of  the  biceps,  passes  be- 
tween these  laminae,  in  the  first  place,  without  adhering  to  them, 
but  afterwards  becomes  confounded  with  them  upon  the  internal 
muscular  eminence. 

From  what  has  preceded,  it  follows  that  the  diverse  lami- 
nae of  the  anti-brachial  aponeurosis  are  principally  attached  to 
the  tendons  of  the  biceps  and  brachialis  internus,  and  conse- 
quently that,  when  these  muscles  contract,  they  must  stretch  the 
fibrous  sheet  sheath  now  under  consideration.  It  also  follows 
that  an  aponeurotic  aperture  seems  to  exist  in  the  middle  of  the  fold 


OP   THE    THORACIC    EXTREMITIES. 

of  the  arm.  This  opening  bears  a  very  great  resemblance  to  that  in 
the  fascia  lata  femoris ;  it  resembles  it  in  its  dimensions,  in  its  oval 
form,  by  its  largest  extremity  being  downwards,  by  its  internal 
semi-circumference  which  is  better  defined  than  the  external,  by 
the  vessels  and  nerves  observed  in  it,  and  lastly,  by  the  cellular 
lamellae  which  close  it,  and  sometimes  prevent  its  being  clearly 
distinguished.  It  commences,  in  general,  some  lines  above  that 
portion  of  the  biceps  which  sends  off  the  fibrous  bandelet  to  the 
aponeurosis,  and  terminates  about  an  inch  below  this  expansion. 
We  observe  in  it,  superiorly,  the  tendon  of  the  biceps,  and  on 
the  inner  side  of  it,  when  the  aperture  is  considerable,  the  bra- 
chial  artery  and  median  nerve,  the  origin  of  the  fibrous  bandelet, 
the  external  border  of  which  sometimes  forms  the  internal  semi- 
circumference  of  this  circle.  Lower  down  than  the  biceps  we 
still  observe  the  brachial  artery,  the  origin  of  the  radial  and  ulnar, 
their  vena?  comites,  the  communication  of  the  median  veins  with 
the  brachial  vein,  the  median  nerve,  the  tendon  of  the  brachialis 
internus,  and  lastly  the  median  basilic  and  median  cephalic  veins, 
which  pass  before  this  aperture. 

It  is  important  to  note  here  that  the  bandelet  given  off  from  the 
inner  margin  of  the  bicipital  tendon  merits,  in  relation  to  the 
artery,  the  greatest  attention.  In  fact,  it  uniformly  crosses  the 
anterior  aspect  of  this  vessel,  as  it  is  passing  upon  the  muscles  of 
the  fore-arm ;  so  that  the  humeral  artery  may  be  secured  below 
this  bandelet,  before  it  divides  into  the  radial  and  ulnar,  and  we 
may  also  tie  it  above  it,  without  being  obliged  to  separate  any 
thing  but  cellular  tissue. 

Upon  the  external  muscular  prominence  the  aponeurosis  of  the 
fold  of  the  arm  is  very  simple  and  does  not  adhere  to  the  mus- 
cles ;  internally,  on  the  contrary,  it  is  firmly  connected  to  the 
muscular  bundles,  sends  intersections  between  them  and  is  blend- 
ed with  their  tendinous  origin  upon  the  fore  part  of  the  epitrochlea 
(internal  condyle).  In  the  bottom  of  the  bicipital  aperture,  it 
passes  back  to  the  articulation  of  the  elbow,  and  is  there  continu- 
ous with  the  ligaments. 


IV. 


The  Muscles. 


They  may  be  arranged  according  to  the  three  principal  emi- 
nences of  the  region. 


OF    THE    THORACIC    EXTREMITIES.  279 

(  a  )  111  the  median  muscular  eminence,  we  find  the  termination 
of  the  biceps ;  the  tendon  of  this  muscle,  applied  upon  the  bra- 
chialis  interims,  makes  a  turn  as  it  dips  into  the  hollow  of  the 
elbow,  in  such  a  manner  as  to  form  an  arc  of  a  circle  the  convexity 
of  which  looks  forwards,  inwards  and  downwards.  Between  this 
tendon,  the  fibrous  bandelet  which  it  gives  to  the  aponeurosis, 
and  the  pronator  teres  muscle,  exists  a  small  triangle,  in  which 
we  see  the  brachial  vessels  and  the  median  nerve  ;  and  it  is  upon 
the  fore  part  of  this  triangle  that  the  basilic  vein  corresponds  to 
the  brachial  artery.  Lower  down,  and  always  on  the  inner  side,  the 
internal  muscular  eminence  partly  conceals  the  tendinous  extre- 
mity of  the  biceps,  at  the  moment  of  its  insertion  into  the  tubercle 
of  the  radius :  when  this  tendon  abandons  the  brachialis  internus 
it  is  reflected  back,  so  that  one  of  its  surfaces  looks  inwards  whilst 
the  other  is  inclined  outwards,  and  twists  upon  itself  in  the  latter 
direction,  in  order  to  pass  upon  the  radius. 

From  this  disposition  it  follows  that,  in  the  physiological  state, 
the  biceps  tends,  in  the  first  place,  to  roll  the  radius  outwards 
and  consequently  to  produce  supination ;  afterwards  to  flex  the 
fore-arm,  if  its  action  continues  after  the  rotation  has  been  effect- 
ed. It  must  be  observed,  in  relation  to  the  movement  of  flexion, 
that  this  muscle  acts  upon  a  lever  of  the  third  order,  and  that  it  is 
inserted  in  a  manner  very  unfavourable  to  this  motion,  since  the 
insertion  is  very  near  the  fulcrum ;  but  that  on  the  other  hand, 
the  species  of  pulley  which  the  brachialis  internus  muscle  forms 
for  it  behind,  by  enlarging  the  angle  under  which  it  is  fixed  to  the 
radius,  partially  compensates  for  the  unfavourable  disposition  just 
indicated. 

In  the  pathological  state,  in  luxations  of  the  fore-arm  back- 
wards, for  example,  this  muscle  counteracts  the  action  of  the 
triceps  and  tends  to  produce  flexion.  In  fractures  of  the  upper 
third  of  the  radius,  the  biceps  also  draws  the  superior  fragment  for- 
wards and  towards  the  median  line  of  the  limb :  whence  the 
necessity  of  keeping  the  fore-arm  flexed,  in  order  to  maintain  the 
surfaces  in  contact. 

Next  the  Brachialis  internus  (brachial  anterieur),  which  forms 
the  bottom  of  the  two  lateral  furrows.  It  is  covered  in  the  mid- 
dle by  the  biceps  and  its  tendon,  by  the  radial  and  musculo- 
cutaneus  nerves ;  by  the  median  cephalic  vein,  in  the  external 


280  OF    THE    THORACIC    EXTREMITIES. 

gutter,  and,  on  the  outer  side,  by  the  external  muscular  eminence. 
Internally,  the  brachial  artery  and  median  nerve  rest  upon  its 
anterior  surface,  which  dips  a  little  under  the  pronator  radii  teres : 
its  posterior  surface  covers  the  whole  of  the  fore  part  of  the  arti- 
culation, without  adhering  to  it.  This  muscle  is  separated  from 
the  anterior  face  of  the  humerus  by  a  considerable  quantity  of 
very  lax  lamellated  cellular  tissue.  When  this  cellular  tissue 
becomes  inflamed,  it  frequently  gives  rise  to  deep  seated  abscesses, 
which  promptly  occasion  disorganization  of  the  bone.  The  very 
strong  and  very  thick  tendon  of  the  brachialis  internus,  in  descend- 
ing upon  the  coronoid  process,  does  not  attach  itself  to  it,  as  is  too 
generally  repeated,  but  simply  covers  this  eminence,  and  is 
evidently  inserted  into  that  crest  which  connects  its  anterior 
border  with  the  internal  border  of  the  ulna.  In  this  manner  the 
insertion  of  the  brachialis  internus  descends  to  a  level  with  the 
tubercle  of  the  radius.  Hence  it  follows  that  this  muscle  really 
acts  upon  the  body  of  the  bone,  and  that  the  apophysis  answers  for  it 
the  purpose  of  a  pulley ;  which  is  much  more  favourable  for  its 
action. 

(  b  )  The  external  muscular  eminence  includes  the  supinator 
longus,  the  extensor  carpi  radialis  longior  and  brevior,  and  the 
supinator  radii  brevis.  The  first  of  these  muscles  is  the  most  im- 
portant in  a  surgical  point  of  view ;  in  fact,  it  is  under  its  inner 
margin  that  we  find  the  radial  artery ;  it  is  between  it  and  the 
brachialis  internus  that  the  radial  nerve  descends  in  the  median 
excavation  of  this  region ;  and  it  is  beneath  it  that  this  nerve 
divides  into  anterior  and  posterior  branches.  From  its  originating 
pretty  high  upon  the  humerus,  even  in  the  brachial  region,  and 
from  its  direction,  it  seems  that  this  muscle  is  better  adapted  to 
act  the  part  of  a  flexor  than  a  supinator  of  the  fore-arm,  which 
appears  more  properly  to  belong  to  the  biceps.  When  the 
humerus  is  fractured  below  the  deltoid  impression,  the  supinator 
longus  acts  like  the  brachialis  internus  upon  the  lower  fragment. 
The  same  may  be  said  of  the  extensor  radialis  longus :  the  latter 
and  the  brevis,  being  more  particularly  applied  upon  the  epicondyle 
(external  condyle),  to  which  they  are  attached,  and  upon  the 
small  head  (eminentia  capilata)  of  the  humerus,  become  the  prin- 
cipal causes  of  displacement  in  fractures  of  this  part  of  the  os 
brachii.  As  for  the  rest,  they  present  nothing  very  remarkable 


OF    THE    THORACIC    EXTREMITIES.  281 

in  this  region ;  they  are  separated,  below  especially,  from  the 
supinator  longus  and  radial  artery,  by  a  fibrous,  or  simply  cellular 
process,  according  to  the  subject. 

As  the  supinator  brevis  adheres  to  the  epicondyle  and  ulna, 
envelopes  the  humero-cubital  articulation  and  almost  all  the  supe- 
rior fourth  of  the  radius,  it  constitutes  a  power  which,  on  the  one 
hand,  opposes  luxations,  and,  on  the  other,  displacement  of  the 
fragments  when  the  upper  part  of  this  bone  is  fractured :  in  this 
respect,  it  is  the  antagonist  of  the  biceps,  for  the  tendon  of  which 
there  is  a  notch  in  its  internal  margin.  The  posterior  branch 
of  the  radial  nerve  passes  through  its  fibres  into  the  posterior 
region  of  the  fore-arm. 

(  c  )  The  Internal  Muscular  Eminence  contains  the  greatest  pro- 
portion of  muscles ;  but  as  all  these  muscles  are  blended  upon 
the  epitrochlea,  it  is  not  necessary  to  examine  each  of  them 
separately.  This  mass  then  is  composed  of  the  pronator  teres, 
flexor  carpi  radialis,  palmaris  longus,  flexor  sublimis,  flexor  carpi 
ulnaris  and  flexor  profundus.  All  these  muscles  are  united  by 
fibrous  intersections,  among  which  there  is  one  which  will  be 
of  great  assistance  to  us  in  finding  the  ulnar  artery  in  the  fore 
arm :  it  is  that  which  is  situated  between  the  flexor  ulnaris  and  flexor 
sublimis.  The  pronator  teres  is  the  only  one  which  deserves 
particular  attention;  it  is  below  it  that  the  ulnar  artery  and 
median  nerve  insinuate  themselves,  in  order  to  escape  from  the 
fold  of  the  arm  through  one  or  more  apertures  which  result  from 
the  separation  of  its  fibres  ;  it  is  before  its  tendon  that  the  radial 
vessels  and  nerves  are  placed  as  they  descend  upon  the  fore- 
arm. As  this  muscle  derives  its  fixed  point  from  the  humerus, 
and  as  it  passes  obliquely  upon  the  radius,  it  follows  that  its  action 
appertains  entirely  to  the  latter  bone ;  which  in  the  natural  state 
produces  pronation  ;  but  in  fractures  this  disposition  is  very  dis- 
advantageous ;  for,  whether  the  fracture  of  the  radius  is  above  or 
below  the  insertion  of  the  pronator  teres,  whether  the  bone  is 
broken  obliquely  or  transversely,  it  will  always  tend  to  obliterate 
the  interosseous  space,  by  drawing  one  of  the  fragments  towards 
ulna. 

36 


or    THE    TliOllACIC 


v.  The  Arteries. 

(  a  )  In  the  fold  of  the  arm  we  find ;  first  the  humeral,  which 
descends  to  it  obliquely  outwards  and  backwards,  in  the  bottom 
of  the  internal  bicipital  furrow.  It  does  not  generally  divide 
until  it  arrives  at  the  tubercle  of  the  radius.  Enveloped  in  the 
laminae  of  the  deep-seated  sheet  of  the  aponeurosis,  the  humeral 
artery  is  covered,  from  above  downwards,  by  the  superficial 
sheet,  by  the  fibrous  slip  of  the  biceps,  and  more  inferiorly  by 
some  cellular  tissue  only.  Anterior  to  these  sheets,  it  corres- 
ponds to  the  median  basilic  vein  and  internal  cutaneous  nerve ; 
it  rests  upon  the  brachialis  internus,  then  upon  the  tendon  of  the 
biceps,  to  which  it  sometimes  adheres :  whence  it  follows  that  in 
carrying  the  arm  in  forcible  pronation,  the  artery,  being  drawn 
by  the  tendon,  is  thus  separated,  by  a  greater  space,  from  the 
median  vein.  Along  the  inner  side  of  the  humeral  artery  the 
median  nerve  always  runs,  which  may  also  be  placed  behind  it ; 
more  internally  and  inferiorly,  it  is  in  relation  with  the  pronator 
teres  muscle  ;  externally,  it  runs  by  the  side  of  the  biceps,  crosses 
the  inner  margin  of  its  tendon,  and  terminates  by  being  free  in 
the  median  excavation. 

In  consequence  of  these  relations  it  is  necessary,  when  about  to 
tie  the  brachial  artery  at  the  fold  of  the  arm,  to  proceed  different- 
ly, according  to  the  point  at  which  we  wish  to  expose  it.  If  the 
operation  is  performed  above  the  articulation,  it  would  be  neces- 
sary to  divide,  in  the  internal  bicipital  groove,  the  integuments 
and  the  fascia  superficialis,  to  separate  the  basilic  vein  and  the 
cutaneous  nerve,  and  to  cut  through  the  aponeurosis,  which  is 
frequently  double  at  this  point,  when  the  artery  will  be  met  with 
between  the  median  nerve,  the  accompanying  vein  and  the  bi- 
ceps muscle. 

If,  on  the  contrary,  we  seek  for  it  in  the  bend  of  the  arm,  the 
incision  should  be  made  parallel  to  the  external  border  of  the  in- 
ternal muscular  eminence ;  the  instrument  will  then  divide  the 
skin  and  the  subcutaneous  layer,  when  the  only  covering  of  the 
artery  will  be  the  cellular  tissue.  If  we  wish  to  expose  it  below 
the  fibrous  bandelet  of  the  biceps,  that  is  to  say  in  the  small 
triangle  indicated  when  on  the  aponeurosis,  we  should  recollect 


OF    THE    THORACIC    EXTREMITIES. 


283 


that,  at  this  point,  the  artery,  nerve  and  tendon  are  very  closely 
approximated,  although  always  in  the  same  relations,  and  that 
the  aponeurosis,  strictly  speaking,  no  longer  exists  before  them. 
If,  finally,  we  wish  to  sieze  it  a  little  higher,  it  will  be  necessary  to 
cut  through  the  superficial  sheet  of  the  aponeurosis  and  the  ban- 
delet  of  the  biceps. 

It  is  necessary  to  note  that  aneurismal  tumours  at  the  fold  of 
the  elbow  are  developed  differently,  according  to  the  point  which 
they  occupy.  If  they  exist  beneath  the  bicipital  fibrous  bandelet, 
the  aponeurosis  will  not  oppose  any  resistance  to  them  inferiorly, 
anteriorly  and  externally,  but  it  will  afford  much,  inwards  and 
upwards ;  the  muscles  and  the  fibrous  sheets  will  always  hinder 
them  from  increasing  in  this  direction.  Consequently,  if  we 
operate  upon  an  aneurism  at  the  elbow  and  the  tumour  is  seated 
below  the  biceps,  we  would  expect  to  find  the  opening  of  the 
vessel  upwards  and  inwards.  If  the  disease  is  situated  immedi- 
ately above  this  bandelet,  and  the  aperture  which  was  mentioned 
when  speaking  of  the  aponeurosis  is  prolonged  in  this  direction, 
the  tumour  will  become  engaged  in  it,  and  will  remain  globular 
and  perhaps  appear  pediculated  ;  if  the  artery  had  been  wound- 
ed or  diseased  under  the  fibrous  bandelet,  it  is  presumable  that 
the  sanguineous  tumor  would  still  pass  through  this  aperture 
and  project  beneath  the  skin. 

Finally,  if  the  aneurism  forms  in  the  superior  part  of  the  re- 
gion, it  will  remain  flattened  for  a  longer  period ;  it  will  project 
less  readily,  externally ;  the  tumour  will  be  less  moveable,  be- 
cause the  aponeurosis,  equally  applied  over  the  whole  anterior 
surface  of  the  sac,  will  more  firmly  resist  the  distending  effort  of 
the  blood,  and,  from  this  circumstance,  it  will  be  less  easy  to  mistake 
the  nature  of  the  disease  at  this  point  than  in  the  two  preceding. 

It  is  not  uncommon  for  the  brachial  artery  to  bifurcate  higher 
up  than  has  been  stated ;  which  is  the  reason  why  it  is  preferable 
to  apply  the  ligature  above  the  elbow  than  at  the  fold  of  the  arm, 
even  when  the  seat  of  disease  will  admit  of  a  choice.  This  bifur- 
cation may  take  place  upon  the  tendon,  below  its  bandelet,  which 
disposition  enters  into  the  normal  state  ;  but  if  higher  than  this 
bandelet,  in  any  point  whatsoever  of  the  rest  of  the  region,  it  is 
then  a  decided  anomaly.  In  the  latter  case,  the  two  branches 
may  remain  by  the  side  of  one  another,  between  the  biceps  and 


284  OF    THE    THORACIC    EXTREMITIES, 

the  median  nerve,  and  enter  together  into  the  fold  of  the  arm ; 
or  the  median  nerve  may  be  situated  between  the  two  branches, 
the  external  passing  before  the  tendon  of  the  biceps,  in  order  to 
get  under  the  supinator  muscle  and  form  the  radial,  without  de- 
scending to  the  bottom  of  the  middle  excavation  of  the  elbow, 
whilst  the  internal  glides,  as  usual,  under  the  pronator  teres  to 
constitute  the  ulnar.  This  is  a  circumstance  which  might  be 
attended  with  danger  in  phlebotomy,  if  we  did  not  pay  attention 
to  it.  It  may  also  happen  that  the  internal  branch  remains  at 
some  distance  from  that  which  is  on  the  outer  side  of  the  median 
nerve,  and,  instead  of  plunging  under  the  internal  muscular  emi- 
nence, passes  before  it  in  order  to  form  the  ulnar,  which  is  then 
subcutaneous ;  in  this  case,  this  internal  branch  is  generally  only 
the  inferior  collateral  (anastomotic)  greatly  developed.  Finally, 
we  have  seen  the  brachial  artery  divide  very  high  up,  and  in  such 
a  manner  that  one  of  its  branches  descended  upon  the  external 
side  of  the  biceps,  in  order  to  constitute  the  radial,  sometimes 
running  under  the  supinator  longus,  as  in  the  normal  state,  and  at 
others,  external  to  the  aponeurosis,  immediately  beneath  the 
skin. 

The  simultaneous  existence  of  two  humeral  arteries  being  a 
very  common  anomaly,  the  ancients  had  observed  it,  and,  by  this 
knowledge,  endeavoured  to  account  for  the  cure  of  aneurisms  at 
the  fold  of  the  arm  by  the  obliteration  of  the  artery.  They  in  fact 
preferred  supposing  that  two  arterial  trunks  existed  in  the  limb,  to 
admitting  the  possibility  of  the  circulation  of  the  limb  being  sup- 
ported after  the  ligature  of  the  brachial  artery.  But  the  research- 
es of  the  celebrated  Scarpa  have  corrected  this  error. 

(  b  )  The  ulnar  (cubitale)  seems  to  be  the  continuation  of  the 
preceding.  Immediately  after  it  separates  from  the  radial  it  dips 
under  the  internal  muscular  eminence,  traverses  the  pronator 
teres,  runs  obliquely  downwards  and  a  little  inwards,  and  places 
itself  between  the  flexor  sublimis  and  profundus.  We  see  that 
it  would  be  very  difficult  to  discover  it  at  the  fold  of  the  arm,  in 
the  usual  state  of  conformation :  therefore,  when  it  is  necessary 
to  obliterate  it,  it  is  more  prudent  and  certain  to  take  up  the 
brachial. 

(  c  )  The  Radial  is  generally  smaller  than  the  ulnar,  and  liefi 
pretty  deep  at  first,  but  rises  a  little  as  it  passes  outwards  and 


OF  THE  THORACIC  EXTREMITIES.  285 

forwards,  under  the  supinator  longus,  in  order  to  follow  the  mid- 
dle furrow  of  the  fore-arm.  This  artery  consequently  becomes 
more  and  more  superficial  as  it  descends  ;  so  that  immediately 
below  its  origin  it  corresponds  to  the  aponeurotic  aperture,  and 
is  only  separated  from  the  radius  by  the  supinator  brevis,  the 
tendon  of  the  biceps  and  some  cellular  tissue.  Anteriorly,  it  is 
separated  from  the  integuments  by  several  fibro-cellular  laminae 
and  the  superficial  layer.  From  these  circumstances,  we  might 
discover  it  by  making  an  incision  upon  the  external  margin  of 
the  pronator  teres;  but  the  operation  would  not  fail  to  be  ren- 
dered difficult  by  the  elevation  of  the  muscular  eminences,  by 
the  presence  of  the  median  cephalic  vein  and  that  of  the  exter- 
nal cutaneous  nerve,  which  we  would  frequently  be  obliged  to 
divide.  As  for  the  rest,  the  radial  nerve  is  then  several  lines 
external  to  it.  Below  the  aponeurotic  aperture,  the  radial  artery 
is  placed  upon  the  pronator  teres,  between  two  thin  fibrous  la- 
minae, having  on  its  inner  side  the  flexor  carpi  radialis,  on  its 
outer,  the  supinator  longus,  the  internal  margin  of  which  usually 
advances  some  lines  before  it.  Then  the  nerve  approaches  so 
close  to  it  that  we  might  strike  it  previous  to  its  entrance  into 
the  anterior  anti-brachial  region :  we  would  therefore  have  to 
divide  the  skin,  the  subcutaneous  layer  and  the  aponeurosis, 
which  will  present  two  sheets  before  the  artery,  if  the  instrument 
is  directed  upon  the  supinator,  and  only  one,  but  thicker,  if  it  is 
inclined  more  towards  the  median  line.  Besides,  the  middle  me- 
dian vein  and  the  principal  branches  of  the  musculo-cutaneous 
nerve  should  be  drawn  outwards,  as  well  as  the  border  of  the 
supinator  longus  muscle.  Then  the  radial  artery  will  be  easily 
distinguished  between  its  nerve,  which  is  external,  and  its  col- 
lateral veins. 

(  d  )  The  Interossea  arising  from  the  ulnar  at  the  moment  that 
it  enters  between  the  two  muscular  layers  of  the  fore-arm,  it 
would  scarcely  be  possible  to  apply  a  ligature  around  it.  It  is 
seated  too  deep  to  be  frequently  wounded. 

(e)  The  recurrens  radialis  anterior  most  frequently  arises 
from  the  trunk  of  the  humeral  on  the  inner  side  of  the  tendon 
of  the  biceps,  upon  which  it  turns  in  order  to  pass  into  the  ex- 
ternal furrow  of  the  region.  As  this  branch  ascends,  it  runs 
between  the  two  portions  of  the  radial  nerve,  between  the  bra- 


286  OF    THE    THORACIC 

chialis  internus  and  the  extensor  radialis  longus,  places  itselt'  be- 
fore the  condyle,  and  goes  to  inosculate  with  the  external  col- 
lateral. It  is  sometimes  so  large  that  we  should  be  apprehensive  of 
placing  a  ligature  immediately  below  it  upon  the  humeral  artery. 

(f)  The  Internal  Recurrents  (Recurrentes  Ulnaris)  originate 
from  the  ulnar ;  the  anterior  glides  along  the  bottom  of  the  inter- 
nal bicipital  furrow,  between  the  brachialis  internus  and  the  inner 
muscular  mass ;  it  ascends  before  the  epitrochlea,  above  which 
it  anastomoses  with  the  inferior  collateral  of  the  arm.  The  pos- 
terior recurrent  passes  between  the  flexor  sublimis,  flexor  pro- 
furidus,  and  flexor  carpi  ulnaris,  in  order  to  pass  behind  the  epi- 
trochlea, etc. 

( g  )  Finally,  the  internal  or  inferior  Collateral  of  the  arm 
(ramus  anastomoticus  magnus  inferior)  is  also  given  off  by  the 
brachial  in  the  region  under  consideration ;  it  is  generally  de- 
tached from  the  trunk  an  inch  or  two  above  the  internal  condyle 
of  the  humerus,  and  as  its  calibre  is  very  considerable  in  certain 
subjects,  it  is  necessary  to  pay  attention  to  it  in  operations.  It  is 
by- means  of  its  anastomoses  with  the  recurrent  arteries  that  the 
circulation  in  the  fore-arm  is  re-established  when  the  humeral 
artery  is  obliterated  at  the  fold  of  the  elbow.  We  have  previ- 
ously stated  that  it  sometimes  supplies  the  place  of  the  ulnar,  in 
which  case  it  is  generally  very  superficial.  We  know  a  physician 
in  whom  this  disposition  is  so  evident,  that  the  pulsations  of  this 
artery  are  very  perceptible  through  the  skin,  from  the  inferior 
third  of  the  arm  to  the  middle  of  the  fore-arm. 

vi.  The  Veins. 

The  superficial  veins  are  the  most  important  of  the  region ; 
their  volume  is  considerable,  and  by  their  communications  with 
one  another  they  form  a  species  of  plexus ;  they  are  : 

( a  )  The  Cephalic,  which  is  situated  upon  the  radial  side  of 
the  region,  in  the  laminae  of  the  subcutaneous  layer,  upon  the 
external  muscular  eminence.  As  this  vein  is  passing  from  the 
anterior  face  of  the  supinator  longus  upon  the  side  of  the  biceps, 
it  receives  the  median  cephalic  and  the  anterior  radial.  The 
external  cutaneous  nerve  runs  by  the  side  of  it,  but  in  such  a 
manner  that  the  former  is  separated  from  it,  in  the  arm,  by  the 


OF    THE    THORACIC    EXTRE3IITIES. 

aponeurosis,  as  far  as  almost  an  inch  above  the  epicondyle ;  and 
upon  the  external  muscular  mass  there  are  only  some  small  ner- 
vous branches  around  the  vein  :  therefore,  in  relation  to  nervous 
accidents,  bleeding  from  the  cephalic  vein  is  less  dangerous  than 
that  from  the  others,  and  the  higher  we  open  the  vein  the  less 
cause  will  we  have  to  apprehend  such  accidents  after  this 
operation. 

(  b  )  The  Basilic  is  situated  upon  the  ulnar  side  of  the  bend  of 
the  arm  ;  it  passes  before  the  epitrochlea  in  order  to  arrive  at  the 
internal  bicipital  furrow,  from  whence  it  proceeds  into  the  bra- 
chial  region.  At  first  it  is  superficial,  like  the  preceding  ;  that  is 
to  say,  that  upon  the  fore-part  of  the  internal  muscular  eminence, 
it  is  included  in  the  laminae  of  the  subcutaneous  layer ;  but  as  it 
ascends  it  gradually  becomes  deeper.  When  opposite  to,  or  a 
little  above  the  epitrochlea.  as  it  is  entering  the  internal  bicipital 
groove,  it  tends  to  insinuate  itself  between  the  laminae  of  the 
brachial  aponeurosis,  which  soon  furnish  for  it  a  complete  sheath. 
It  is  accompanied  by  the  internal  cutaneous  nerve,  included  in 
the  same  aponeurotic  sheath,  and,  above  the  muscular  eminence, 
almost  always  situated  upon  its  inner  side :  lower  down,  the  prin- 
cipal branches  of  this  nerve  continue  to  follow  the  vessel,  but 
sometimes  internal  to,  at  other  times  crossing  before  it ;  and  again 
they  are  behind,  or  upon  its  outer  side.  Occasionally  they  form 
around  it  a  species  of  plexus :  in  short,  these  nervous  filaments 
are  so  disposed  relatively  to  the  basilic,  that  it  is  scarcely  possible 
to  open  this  vein  without  running  the  risk  of  wounding  them.  In 
this  respect,  anatomical  knowledge  and  the  precautions  which  we 
might  take  will  be  but  of  slight  assistance,  on  account  of  the 
numerous  varieties  in  the  relative  position  of  these  organs.  On 
the  one  hand,  if  the  operation  is  performed  upon  the  side  of  the 
biceps,  we  will  perhaps  avoid  the  principal  nerve  by  puncturing 
the  vein  from  the  external  towards  the  internal  side  ;  but  if  we 
should  strike  it,  its  volume  in  this  place  is  so  considerable,  that 
pretty  serious  symptoms  might  be  the  consequence;  besides, the 
vein  being  deeply  situated,  it  would  not  always  be  easy  to  reach 
it.  On  the  other  hand,  if  we  bleed  upon  the  eminence  of  the 
anti-brachial  muscles,  the  nerves  are  indeed  smaller,  but  if  they 
escape  the  instrument  it  will  be  by  chance  alone.  Venesection, 


288  OF    THE    THORACIC    EXTREMITIES, 

therefore,  from  the  trunk  of  the  basilic  should  not  be  performed 
when  we  can  do  otherwise. 

(  c  )  The  Median  is  actually  the  most  important,  in  a  surgical 
point  of  view,  of  the  three  veins  at  the  fold  of  the  elbow.  We 
generally  meet  with  it  in  the  lower  part  of  the  region,  in  the  me- 
dian groove,  occasionally  inclined  upon  the  external  eminence, 
sometimes  also  more  internally ;  it  is  almost  always  single,  and 
thus  ascends  as  far  as  the  aperture  of  the  aponeurosis.  There  it 
divides  into  three  branches  ;  one,  very  short,  which  almost  imme- 
diately empties  itself  into  the  deep-seated  veins,  in  the  same 
manner  that  the  saphena  major  does  into  the  femoral.  The  other 
two  remain  superficial,  follow  the  two  grooves  of  the  fold  of  the 
elbow,  passing  upon  the  sides  of  the  biceps  in  order  to  enter,  the 
one  into  the  basilic,  and  the  other  into  the  cephalic ;  so  that,  in 
the  regular  conformation,  these  two  branches,  with  the  two  trunks 
into  which  they  open,  represent  somewhat  the  letter  M.  The 
median  basilic  vein  consequently  runs  along  the  outer  side  of 
the  internal  muscular  eminence,  becoming  deeper  and  deeper  in 
proportion  to  its  ascent :  it  is  surrounded  by  some  twigs  of  the 
internal  cutaneous  nerve,  and  these  sensitive  filaments,  in  gene- 
ral of  small  size,  are  pretty  uniformly  situated  before  the  vein. 
Its  direction  is  such  that  it  crosses  the  artery,  which  is  behind 
it,  very  obliquely ;  but  this  direction  is  susceptible  of  numerous 
varieties ;  so  that  in  some  subjects  the  vein  is  almost  parallel  to 
the  artery,  whilst  in  others  it  crosses  it  at  a  considerable  angle, 
In  the  the  latter  case,  which  is  fortunately  the  most  frequent,  we 
run  less  risk  of  wounding  the  arterial  trunk  by  making  the  punc- 
ture near  the  extremities  of  this  vein.  In  the  other,  the  dangers 
are  almost  always  the  same,  at  whatever  point  we  may  choose  : 
however,  as  the  artery  lies  deeper  superiorly  and  inferiorly  than  in 
the  middle,  we  should  prefer  one  of  the  two  former  points,  the 
second  especially.  The  median  basilic  is  nevertheless  always 
separated  from  the  humeral  artery  by  fibrous  or  cellular  laminae, 
according  to  the  place  at  which  we  examine  it.  Thus,  anterior 
to  the  tendon  of  the  biceps,  and  below  the  bandelet  which  it  fur- 
nishes to  the  aponeurosis,  these  vessels  are  separated  by  a  lamel- 
lated  cellular  tissue  only,  which  there  forms  a  layer  the  thickness 
of  which  varies  in  proportion  to  the  embonpoint  of  the  individ- 
ual ;  whence  it  follows,  that,  in  fat  persons,  we  may  introduce  the 


OF   THE    THORACIC    EXTREMITIES.  289 

lancet  very  deeply  without  striking  the  artery  ;  whilst  in  thin  sub- 
jects it  will  often  be  difficult  to  avoid  it.  Hence  it  is  in  the  latter 
case  that  we  most  frequently  see  aneurism  consequent  upon  bleed- 
ing. One  of  three  things  may  then  happen :  1st,  either  the  in- 
strument will  traverse  the  vein  from  one  side  to  the  other  and 
penetrate  the  anterior  paries  of  the  artery,  making  a  large  open- 
ing in  it :  in  this  case  the  blood  will  be  immediately  thrown  out  in 
jets,  and  will  only  be  stopped  by  the  suspension  of  the  circula- 
tion in  the  limb ;  a  suspension  which  may  be  produced  by  syn- 
cope, but  for  a  few  moments  only,  by  the  ligature  of  the  artery 
above  the  elbow,  or  by  pressure  above  the  puncture  or  upon  the 
wound  itself.  It  is,  in  general,  when  we  have  attempted  the  lat- 
ter method  that  the  blood  extravasates  into  the  cellular  tissue,  and 
produces  the  false,  primitive,  or  diffused  aneurism : — 2d,  or  the 
point  of  the  lancet  will  have  wounded  the  artery  very  slightly, 
and  the  accident  will  not  be  detected  at  the  time  of  the  opera- 
tion ;  the  wound  of  the  vein  and  of  the  cellular  covering  of  the 
artery  will  cicatrize :  but  the  internal  and  middle  arterial  tunics 
being  insusceptible  of  agglutination  when  they  have  been  divided, 
the  impulse  of  the  blood  will  not  delay  to  give  rise  to  a  tumour 
at  this  part,  constituted  by  the  fluid  which  will  be  extravasated 
in  a  cyst  furnished  by  the  cellular  tunic :  it  is  in  this  manner  that 
the/«/se  consecutive,  or  circumscribed  aneurism  is  formed,  on  the 
fore-part  of  which  the  veins  usually  remain  applied.  This  form 
of  aneurismal  tumour  is  developed  as  frequently  when,  after  the 
artery  has  been  pricked  in  bleeding,  compression  has  been  made 
upon  the  wound ;  then,  in  fact,  the  haemorrhage  may  be  suspend- 
ed, and  the  patient  apparently  cured ;  but  after  a  certain  period, 
in  consequence  of  some  exertion,  some  sudden  movement,  or 
even  without  any  appreciable  cause,  the  lips  of  the  arterial 
wound  separate  and  the  aneurism  forms : — 8d,  or  lastly,  the  cor- 
responding parietes  of  both  vessels  are  so  exactly  applied  against 
each  other  that,  after  the  cicatrization  of  the  subcutaneous  wall 
of  the  vein,  the  red  blood  passes  into  the  latter  by  the  opening 
which  is  common  to  it  and  the  artery,  and  thus  forms  the  disease 
so  well  described  by  Hunter,  Cleghorn,  and  Guattani  under  the 
name  of  Aneuresmal  Varix.  This  pathological  state  may  also 
be  complicated  with  a  circumscribed  aneurism :  that  is  to  say. 

3PV 
7 


*290  OF    TliL    THORACIC    EXTREMITIES. 

after  the  aneurismal  varix  has  existed  for  a  greater  or  less  length 
of  time,  it  may  happen  that  the  two  vascular  parietes  separate 
by  the  relaxation  of  the  cellular  tissue  which  unites  them,  and  a 
sanguineous  tumor  forms  between  them,  without  interrupting  the 
course  of  the  fluid  from  one  vessel  into  the  other.  This  disposi- 
tion which  has  been  noticed  by  Messrs.  Parck,  Physic,  etc.,  con- 
stitutes what  English  pathologists  call  Varicose  Aneurism. 

In  the  last  two  species  of  Aneurism,  anatomy  demonstrates, 
and  observation  has  proved,  that  a  cure  cannot  be  accomplished 
with  certainty  unless  a  ligature  is  placed  above  and  below  the  dis- 
ease. In  fact,  on  the  one  hand,  the  collateral  arteries  are,  gen- 
erally, in  such  cases,  greatly  enlarged  ;  the  functions  of  the  vein 
being  changed,  its  parietes  have  assumed  the  most  of  the  char- 
acters peculiar  to  the  arteries ;  the  latter,  on  the  contrary,  per- 
forming in  part  the  functions  of  the  venous  system,  have  become 
weaker.  It  also  follows  that  after  the  application  of  a  simple 
ligature  above  the  lesion,  neither  the  vein  nor  the  artery  are  oblitr 
erated  below  it,  and  the  disease  persists.  On  the  other  hand, 
MM.  Richerand,  Dupuytren,  J.  Cloquet,  &c.  have  seen  subjects 
affected  with  these  aneurisms,  in  whom  the  operation  had  been 
performed  according  to  AnePs  method  without  any  advantage : 
on  the  contrary,  the  life  of  some  of  them  has  been  seriously 
compromised,  and  in  others  it  became  necessary  to  resort  to  am- 
putation of  the  limb  ;  finally,  in  the  most  fortunate  circumstances, 
a  second  operation  has  produced  a  complete  cure.  These  cases, 
therefore,  demand  the  old  operation. 

Above  the  point  which  has  just  been  examined,  the  median 
basilic  vein  is  separated  from  the  artery,  in  the  first  place,  by  the 
fibrous  bandelet  of  the  biceps,  afterwards  by  the  aponeurosis, 
upon  which  the  vein  is  applied.  Here,  embonpoint  or  emaciation 
produce  but  little  difference  in  the  relations  of  the  vessels,  be- 
cause the  fat  always  accumulates  between  the  vein  and  the  skin, 
and  not  between  the  vein  and  the  aponeurosis,  nor  between  the 
latter  and  the  artery.  It  must  nevertheless  be  admitted,  that,  in 
individuals  very  much  emaciated,  the  cellular  lamina?  united  to 
the  fibrous  layer  are  firmly  applied  to  one  another ;  so  that  the 
aponeurotic  envelope  of  the  arm  is  actually  agglutinated  with  the 
corresponding  parietes  of  the  two  vessels.  In  this  case  we  con- 


OP   THE    THORACIC    EXTREMITIES.  291 

ceive  that  the  only  rational  method  of  avoiding  the  artery  con- 
sists in  introducing  the  lancet  very  obliquely,  in  order  to  puncture 
the  vein  in  its  anterior  half  only. 

Whenever  we  draw  blood  from  the  median  basilic  vein,  as  the 
humeral  artery  is  bound  down  upon  the  tendon  of  the  biceps  by 
the  aponeurosis,  or  by  the  fibro-cellular  tissue  which  fills  the  aper- 
ture of  the  latter,  we  will  considerably  increase  the  depth  of  this 
vessel  by  turning  the  fore-arm  in  forced  pronation.  Then,  in 
fact,  in  proportion  as  the  tendon  is  drawn  downwards,  the  three 
muscular  eminences  become  more  prominent,  and  consequently 
render  the  veins  more  superficial.  The  ancient  surgeons  also 
recommended  this  plan  when  about  to  open  the  vein  under  con- 
sideration, with  a  view  of  preventing  a  puncture  of  the  aponeu- 
rosis and  tendon  ;  but,  as  it  relates  to  this,  it  is  now  proved  that 
the  severe  symptoms  which  sometimes  follow  venesection,  must  be 
referred  to  other  causes  than  the  wounding  of  the  fibrous  elements 
of  the  region.  All  that  we  can  concede  to  this  idea  of  the  an- 
cients is,  that  by  puncturing  the  aponeurosis  under  the  vein,  we 
may,  in  certain  cases,  determine  inflammation  of  the  deep  cellu- 
lar tissue ;  and  as  the  tumefaction  consequent  upon  it  will  be 
repressed  by  the  fibrous  expansion,  a  species  of  strangulation 
and  more  or  less  formidable  phenomena  would  result  from  it. 

Those  symptoms  which  are  referred  to  pricking  the  aponeu- 
rosis, tendon  or  nerves,  almost  universally  arise  from  phlebitis,  or 
from  the  formation  of  vast  phlegmonous  abscesses  under  the  skin. 
Phlebitis  was  unknown  to  the  ancients ;  but  it  seems  to  us  that 
many  moderns  have  caused  it  to  perform  too  extensive  a  part  in 
the  inflammations  which  follow  bleeding  from  the  arm,  and  we 
think  that  they  have  too  frequently  attributed  to  it  the  simple  or 
phlegmonous  erysipelas  produced  by  this  operation.  During  the 
present  year,  we  have  seen  at  the  Hospital  of  the  Faculte,  six 
patients  in  whom,  after  a  puncture  with  the  lancet,  pain,  redness, 
and  tumefaction  at  the  fold  of  the  arm  took  place :  these  symp- 
toms extended  rapidly  throughout  the  entire  limb,  and  fever  was 
excited ;  four  of  these  patients  recovered,  after  the  formation  of 
more  or  less  extensive  abscesses  ;  the  other  two  died,  and  in  these 
the  skin  was  detached,  by  the  disorganization  of  the  subcutaneous 
adipo-cellular  layer,  from  the  hand  to  the  shoulder.  In  the 


OP    Tilt!   THORACIC    EXTREMITIES. 

midst  of  this  disorganization  the  veins  were  healthy,  and  their 
calibre  had  undergone  no  alteration. 

A  fact  of  this  kind  was  recently  observed  by  M.  Ch.  Delange, 
in  a  soldier  who  died  at  the  Hospital  Val-de-grace.  The  pus 
had  spread  throughout  the  whole  length  of  the  limb,  even  into  the 
thorax ;  yet,  notwithstanding,  the  internal  coat  of  the  vessel  pre- 
sented no  decided  inflammatory  character.  M.  Broussais  him- 
self, who  assisted  at  the  autopsic  examination,  could  riot  de- 
tect any. 

The  Median  Cephalic  is  generally  a  little  larger  than  that 
which  has  just  been  examined.  As  it  ascends  outwards,  included 
in  the  radio-bicipital-furrow,  it  is  accompanied  by  the  internal 
branch  of  the  musculo-cutaneus  nerve.  This  nerve,  which  is 
always  of  a  certain  volume,  sometimes  passes  before,  much  more 
frequently  behind  the  vein,  which  on  its  part  crosses  the  radial 
artery  near  its  origin.  Its  distance  from  the  humeral  artery  is 
greater  in  proportion  as  it  approximates  the  trunk  of  the  cephalic, 
and  it  is  never  so  near  this  artery,  unless  by  anomaly,  as  to  en- 
danger a  wound  of  the  latter  in  drawing  blood  from  the  external 
median ;  but  it  should  be  observed,  that  in  cases  wherein  the 
radial  artery  comes  from  the  brachial  region,  thrS  vein  is  generally 
contiguous  to  it.  The  median  cephalic  is  usually  less  directly 
applied  upon  the  aponeurosis  than  the  basilic;  the  groove  in 
which  it  is  imbedded  being  broader,  and  the  cellular  tissue  more 
abundant,  it  follows  that  it  generally  appears  deeper,  and  rolls 
less  under  the  finger ;  the  tissues  upon  which  it  rests  being  less 
solid,  less  resistant,  it  sometimes  happens  that  after  having  opened 
it,  the  flow  of  blood  is  with  some  difficulty  restrained,  because 
the  pressure  is  not  made  so  exactly  upon  it  as  upon  the  internal 
median.  Every  one  knows  also  that  occasionally,  when  \ve  wish 
to  stop  the  bleeding  from  one  of  these  veins,  the  blood  continues 
to  flow,  notwithstanding  we  apply  the  thumb  below  the  puncture. 
This  peculiarity,  with  regard  to  both,  arises  from  our  pressing 
upon  the  middle  median  vein  below  its  division,  and  from  the 
blood  returning  by  the  deep  median  ;  or,  with  respect  to  the  me- 
dian cephalic  in  particular,  from  the  aponeurosis  behind  it  not  af- 
fording sufficient  resistance  to  admit  of  the  obliteration  of  thi? 
canal  by  the  pressure  of  the  finger. 

* 


OP   THE    THORACIC    EXTREMITIES. 

The  Trunk  of  the  Median  runs  parallel  to  the  internal  margin 
of  the  supinator  longus ;  so  that  it  is  only  separated  from  the 
radial  artery  by  the  aponeurosis,  and,  more  frequently,  by  the 
border  of  this  muscle.  Therefore,  when  we  wish  to  lay  bare 
the  artery,  we  are  obliged  to  push  the  vein  towards  the  ulnar 
side  of  the  region.  The  latter  is  often  surrounded  by  several 
nervous  filaments  from  the  musculo-cutaneus,  and  the  internal 
branch  of  this  nerve  almost  always  runs  along  its  outer  side  ;  for 
which  reason,  phlebotomy,  although  easy  here,  might  give  rise  to 
serious  symptoms. 

From  all  these  considerations  we  draw  the  following  conclu- 
sions :  1st.  That  venesection  is  more  easy  from  the  internal  me- 
dian, but  also  more  hazardous  than  from  the  external ;  2d.  that 
this  operation  may  be  performed  upon  all  the  veins  of  the  fold  of 
the  arm ;  3d.  that,  if  in  thin  persons  these  vessels  are  large  and 
distinct,  they  also  roll  more  easily  under  the  skin,  on  account  of 
the  mobility  of  the  cellular  titsue  ;  4th.  that  if,  in  very  fat  sub- 
jects, it  is  sometimes  very  difficult  to  gee  and  feel  them,  they  are, 
by  way  of  compensation,  fixed,  scarcely  moveable,  and  more 
remote  from  the  organs  \vhich  should  be  avoided:  hence,  in 
eastern  nations,  Turkey  for  example,  those  empirics  who  make 
bleeding  their  trade,  plunge  their  enormous  lancets  without 
hesitation,  an  inch  deep  into  the  plump  arms  of  these  indolent 
people,  especially  of  the  females,  almost  all  of  whom  possess 
considerable  embonpoint ;  5th.  that  the  flammette,  used  by  Ger- 
man surgeons,  applied  upon  the  median  basilic  would  be  dan- 
gerous, on  account  of  the  vicinity  of  the  artery;  and,  upon  the 
median  cephalic,  would  often  fail  to  open  the  vein,  on  account  of 
the  suppleness  of  the  tissues  in  which  it  is  imbedded  ;  6th.  that 
the  thrombus  must  supervene  more  frequently  in  thin  individuals 
than  in  those  of  an  opposite  condition,  in  consequence  of  the 
facility  with  which  the  parts  slide  over  one  another,  thereby 
destroying  the  parallelism  of  the  opening.  This  accident  is  most 
liable  to  occur  when,  for  the  purpose  of  removing  the  artery,  the 
fore-arm  is  placed  in  a  state  of  forced  pronation  during  the  punc- 
ture, because  then,  if  we  do  not  afterwards  retain  the  arm  in  the 
same  position  whilst  the  blood  is  flowing,  the  aperture  in  the  skin 
will  no  longer  correspond  with  that  of  the  vein,  and  the  blood 
will  become  extravasated  into  the  cellular  tissue. 


'294  OF    THE    TJIOKACIC    EXTREMITIES. 

We  find  as  many  deep-seated  veins  as  arterial  branches  ;  some- 
times more.  The  radial  is  frequently  double  ;  the  ulnar  some- 
times presents  the  same  disposition,  as  well  as  the  humeral.  At 
the  place  where  the  two  former  unite  in  order  to  form  the  latter, 
they  receive  the  communicating  branch  of  the  median,  so  that  in 
this  situation  there  is  a  species  of  confluence.  When  there  is 
only  one  vein  for  each  artery  the  radial  is  placed  on  the  inner, 
the  ulnar  on  the  outer  side  ;  the  humeral  also  is  most  frequently 
external,  sometimes  anterior  and  even  internal.  As  to  the  small- 
er branches,  their  course  is  similar  to  that  of  the  arteries. 

vii.  The  Lymphatics. 

These  vessels  consist  of  two  sets,  a  superficial  and  deep-seated  : 
the  former  is  most  abundant,  and  both  accompany  the  blood-ves- 
sels, the  veins  in  particular.  They  are  so  large,  especially  in  the 
internal  furrow,  that  if  divided  in  venesection  they  will  give  forth 
considerable  lymph.  When  pus,  or  other  pathological  products, 
exist  in  the  tissues  through  which  they  pass,  they  readily  become 
engorged  and  inflamed.  Also,  after  bleeding,  they  often  seem  to 
us  to  be  the  point  at  which  erysipelatous  inflammations,  so  fre- 
quently consequent  upon  this  operation,  originate.  We  even 
think  that  what  is  sometimes  referred  to  inflammation  of  the 
veins  not  unfrequently  appertains  to  the  lymphatics  alone. 

The  Lymphatic  Glands  are  situated  in  the  internal  bicipital 
groove,  before  and  above  the  trochlea,  and  are  generally  three, 
four,  and  even  five  in  number.  These  bodies  are  situated  be- 
tween the  deep-seated  cellular  and  aponeurotic  layers.  They 
sometimes  become  engorged  and  considerably  enlarged  from  sup- 
purations of  the  hand  and  fore  arm,  in  consequence  of  inflamma- 
tions, blisters,  or  any  morbid  affection  whatsoever. 

viii.  The  Nerves. 

These  are  also  superficial  and  deep  seated. 

Among  the  former,  we  find,  first,  the  muscuio-citianeus :  this 
cord  is  the  largest ;  it  comes  from  under  the  aponeurosis  upon 
the  external  side  of  the  biceps,  about  one  inch  above  the  articu- 
lation. A  little  lower  down  it  divides,  and  its  branches  generally 


OF   THE    THORACIC    EXTREMITIES.  295 

follow  the  veins  which  unite  to  form  the  cephalic  trunk.  We 
have  already  said  that  the  largest  of  these  branches  is  situated 
upon  the  radial  side  of  the  common  median. 

Next,  the  Internal  Cutaneous,  which  is  situated  in  the  ulnar 
furrow.  Its  twigs  are  smaller  than  those  of  the  preceding,  and 
are  distributed  around  the  branches  which  go  to  empty  into  the 
basilic  and  median  veins.  The  filaments  of  the  latter  nerve  are 
almost  always  before  the  veins,  whilst  those  of  the  musculo-cuta- 
neus  are  generally  situated  behind  it. 

The  second  set  also  comprises  two  nerves.      In  the  first  place 
we  meet  with  the  radial ;  this  nerve  coming  from  the  posterior 
part  of  the  arm,  places  itself  between  the  brachialis  internus  and 
supinator  longus,  then  between  the  biceps  and  extensor  radialis 
longior,  and  at  length  divides  opposite  to  the  articulation.     Thus 
far  it  has  continued  in  the  bottom  of  the  radial  furrow,  separated 
from  the  humeral  artery  by  the  entire  thickness  of  the  brachialis 
internus  and  biceps  muscles,  and  sufficiently  distant  from  any  vein 
to  be  out  of  danger  in  bleeding.     Its  posterior  branch  turns  out- 
wards, .passes  between  the  extensor  radialis  brevior  and  supinator 
brevis,  traverses  the  fibres  of  the  latter  and  penetrates  into  the 
posterior  region  of  the  elbow.     As  this  branch  lies  very  near  the 
head  of  the  radius,  and  turns  over  it,  it  may  be  stretched,  com- 
pressed, etc.  in  luxations  of  the  humeral  extremity  of  this  bone 
forwards.     The  radial  nerve,  properly  so  called,  is  constituted  by 
the  anterior  branch.     Its  direction  seems  to  be  a  continuation  of 
that  of  the  trunk  ;  it  rises  a  little,  in  order  to  descend  parallel  to 
the  length  of  the  lirnb  behind  the  great  supinator,  and  is  soon 
found  by  the  side  of  the  radial  artery.     Hence  it  follows  that  the 
anterior  branch  of  the  radial  nerve  is  the  more  remote  from  the 
artery  the  nearer  it  approximates  its  origin,  and  that  these  organs 
are  separated  by  a  triangular  space  with   superior  base,  in  which 
we  see  the  tendon  of  the  biceps  and  a  part  of  that  of  the  brach- 
ialis internus  muscle. 

Next  the  Median  Nerve.  It  enters  this  region  without  any 
diminution  of  its  volume.  It  is  almost  constantly  situated  upon 
the  ulnar  side  of  the  artery,  and  rests  upon  the  fore  part  of  the 
brachialis  internus  muscle ;  it  descends  into  the  hollow  of  the 
elbow  along  the  inner  portion  of  the  bicipital  tendon  and  cover- 
ed by  the  radial  side  of  the  internal  muscular  mass*  always  pre~ 


296  OF    THE    THORACIC    EXTREMITIES. 

serving  its  relations  with  the  artery,  to  which  it  is  then  very  closely 
approximated.  In  passing  through  the  pronator  teres  muscle  in 
order  to  place  itself  before  the  flexor  profundus,  this  nerve  is  found 
behind  the  radial  artery,  or  rather  between  it  and  the  ulnar ;  so 
that  the  latter  removes  from  it  considerably  in  passing  towards 
the  flexor  carpi  ulnaris  muscle.  It  is  when  running  under  the 
muscular  eminence  that  the  median  gives  off  many  filaments,  and 
it  is  previous  to  its  exit  from  the  region  that  it  furnishes  the  inter- 
osseous,  and  the  various  twigs  which  sometimes  follow  the  ulnar 
artery.  According  to  this  disposition  it  would  be  difficult  for  this 
large  nervous  cord  to  be  injured  in  luxations  of  the  elbow,  but  it 
may  be  struck  with  the  point  of  the  lancet  when  we  open  the  ba- 
silic vein.  In  the  operation  for  aneurism,  it  may  embarrass  the 
surgeon,  and  be  taken  for  the  artery,  when  the  pathological  state 
oft  he  tissues  no  longer  permits  us  to  distinguish  its  characters  rea- 
dily. It  should  not,  however,  be  comprised  in  the  ligature,  for 
paralysis  of  the  first  four  fingers  would  necessarily  follow,  if  the 
limb  does  not  fall  into  gangrene. 

ix.  The  Skeleton. 

It  comprises  the  anterior  portion  of  the  articulation,  of  the  in- 
ferior fifth  of  the  humerus,  and  of  the  superior  fourth  of  the  ulna 
and  radius. 

The  joint  here  presents  three  grooves  and  four  eminences,  cov- 
ered by  a  fibrous  lamina  of  greater  or  less  thickness.  In  order 
to  distinguish  these  objects,  the  limb  must  be  extended.  The 
median  groove  is  that  in  wrhich  the  coronoid  process  of  the  ulna 
rolls ;  it  is  covered  by  the  brachialis  internus,  corresponds  to  the 
humeral  artery  and  median  nerve,  and  it  is  in  this  point  that  the 
ligament  of  the  articulation  is  the  strongest.  The  second  groove 
exists  between  the  condyle  and  the  internal  tuberosity ;  it  is  not 
articular,  and  is  covered  by  the  origin  of  the  ulnar  muscular  mass 
The  third,  or  external,  rolls  upon  the  superior  extremity  of  the 
radius ;  it  is  particularly  concealed  by  an  almost  isolated  bundle 
of  the  brachialis  internus  muscle. 

Of  the  four  eminences,  the  external,  formed  by  the  condyle 
or  small  head  of  the  humerus,  surmounted  by  the  epicondyle,  is 
the  most  developed:  it  is  concealed  by  the  external  muscular 


OP    THE    THORACIC    EXTREMITIES.  297 

mass.  That  which  comes  next  represents  a  species  of  crest,  which 
rolls  upon  the  ulna,  and  even  upon  the  radius  also.  The  third, 
very  large,  is  the  trochlea,  and  the  fourth,  which  is  inclined  con- 
siderably backwards,  is  the  epitrochlea.  Above  these  different 
points,  the  humerus  presents  a  species  of  transverse  furrow, 
which  is  produced  by  the  anterior  surface  of  the  articular  pulley 
being  raised  forwards.  It  is  upon  this  furrow  that  the  knife  fre- 
quently strikes,  when  carried  too  high  in  disarticulating  the  fore- 
arm according  to  the  method  of  M.  Dupuytren ;  but  this  mistake 
will  always  be  avoided,  if  we  take  the  precaution  to  draw  the 
instrument  from  one  humeral  tuberosity  to  the  other,  keeping  it 
upon  a  line  a  little  distance  below  them.  In  this  furrow,  two 
fossettes  are  observed  :  one,  small  and  of  slight  depth,  above  the 
external  humeral  groove,  receives  the  fore-part  of  the  head  of  the 
radius  in  the  forced  flexion  of  the  fore-arm ;  the  other,  very  deep 
and  broad,  receives  the  coronoid  process  of  the  ulna,  in  the  same 
movement,  above  the  median  articular  groove.  Still  higher,  the 
anterior  aspect  of  the  humerus  is  flattened,  and  entirely  covered 
by  the  brachialis  internus  muscle. 

Below  the  articulation,  the  ulna  presents  in  the  first  place,  the 
coronoid  process  which  may  be  more  or  less  curved  upon  the  os 
brachii,  and  thereby  powerfully  oppose  its  luxation.  In  all  cases 
in  which  amputation  of  the  fore-arm  at  the  joint  is  required,  this 
eurvature  should  be  recollected ;  for  it  would  be  in  vain  to  at- 
tempt introducing  the  knife  between  the  osseous  surfaces  until 
this  process  is  depressed.  Its  anterior  surface  inclines  down- 
wards and  forms  another  curve  with  an  inferior  concavity,  below 
which  the  brachialis  internus  is  inserted,  and  where  the  trochlea 
of  the  humerus  lodges  when  luxated  forwards.  It  is  at  this  point, 
and  especially  in  the  radial  and  olecranoid  excavations  of  the 
humerus,  that  those  small  clusters  of  synovial  tissue  exist,  which, 
when  attacked  with  chronic  or  acute  inflammation,  frequently 
form  a  focus  whence  white  swellings  and  other  serious  diseases 
of  the  joint  radiate. 

The  Radius  presents,  in  this  region,  its  head,  enveloped  by  the 
annular  ligament,  the  supinator  brevis,  and  all  the  muscles  of  the 
epicondyle ; — its  neck,  the  bicipital  tubercle,  and  the  commence- 
ment of  the  body  of  the  bone :  it  is  upon  the  neck  that  the  hu- 
meral condyle  vests  when  displaced  forwards.  Above  the  bicipi 

38 


%  OF   THE    THORACIC    EXTREMITIES. 

tal  tubercle,  between  the  radius  and  ulna,  there  is  a  space,  through 
which  an  instrument  may  be  passed,  from  before  backwards, 
without  fracturing  the  bones.  From  what  has  just  been  said  we 
perceive  that,  if  the  humerus  can  easily  slip  upon  the  anterior 
surface  of  the  fore-arm,  it  would  be  very  difficult  for  it  to  pass 
outwards  or  inwards,  unless  the  ligaments,  muscles,  and  even 
the  vessels  are  at  the  same  time  lacerated.  On  the  other  hand, 
the  inequality  of  all  these  surfaces,  and  their  extensive  transverse 
dimensions,  render  the  articulation  very  solid,  and  only  admit  of 
the  motions  of  flexion  and  extension,  always  joining  to  them  the 
rotatory  movement  of  the  radius. 

Recapitulation.  In  the  anterior  region  of  the  elbow  we  ob- 
serve the  following  order  of  super-position  ; — 1st,  the  skin  ;  2d, 
the  fascia  superficialis,  or  the  subcutaneous  layer,  varying  consid- 
erably in  thickness,  and  including  the  superficial  veins,  nerves, 
and  lymphatic  vessels;  3d,  the  aponeurosis,  thicker  upon  the 
external  and  internal  eminences  and  furrows,  thinner,  and  actu- 
ally perforated  by  a  large  aperture  in  the  median  excavation : 
4th,  the  arteries,  muscles,  deep-seated  nerves,  veins,  and  lymph- 
atics :  5th,  and  lastly,  the  articulation  and  the  bones.  But  we 
have  observed  that  these  different  layers  are  very  variable  in 
thickness  in  the  different  points  at  which  they  may  be  examined. 

Sect.  2.  Posterior  Region  of  the  Elbow,  or  the  Elbow,  properly 

so  called. 

The  surface  of  the  elbow  presents  three  very  distinct  osseous 
projections  which  are ; — externally,  the  epicondyle ;  internally, 
the  epitrochlea,  and  in  the  middle  the  olecranon,  which  is,  how- 
ever, a  little  nearer  to  the  internal  than  the  external  tuberosity. 
When  the  limb  is  extended  these  eminences  are  situated  nearly 
upon  the  same  line,  but  then  the  olecranon  is  scarcely  prominent  ; 
when  flexed,  they  represent  a  triangle,  the  apex  of  which  is  in- 
ferior ;  and  the  olecranon,  which  then  seems  to  be  very  much 
elongated,  is  below  the  articulation.  The  middle  prominence  is 
prolonged  upwards,  under  the  form  of  a  flattened  cord,  which 
is  produced  by  the  tendon  of  the  triceps ;  and  downwards  by 
means  of  the  ulna.  In  whatsoever  position  the  limb  is  placed, 
the  internal  eminence  is  equally  prolonged  superiorly  by  the 


OF   THE    THORACIC    EXTREMITIES.  299 

epitrochlo-humeral  (inner  intermuscular)  ligament,  and  inferiorly, 
by  the  extensor  carpi  ulnaris  muscle.  As  the  external  ascends 
it  becomes  less  distinctly  marked  by  the  outer  border  of  the  hu- 
merus ;  immediately  below  it  we  may  distinguish  a  transverse 
groove,  which  corresponds  to  the  humero-radial  articulation,  then 
the  head  of  the  radius,  which  may  easily  be  felt  rotating  in  its 
annular  ligament. 

These  three  projections  are  separated  by  two  grooves,  of 
which  the  internal,  which  is  deepest,  passes  between  the  olecra- 
non  and  epitrochlea.  This  species  of  gutter  insensibly  contracts 
above  the  joint,  by  the  gradual  approximation  of  the  internal  por- 
tion of  the  triceps  and  of  the  epitrochlo-humeral  intersection.  It 
is  in  this  groove  that  we  find  the  ulnar  nerve.  The  external  sep- 
arates the  epicondyle  from  the  olecranon ;  it  is  more  superficial 
and  irregular  than  the  preceding ;  in  ascending,  it  is  almost  im- 
mediately lost  behind  the  tendon  of  the  triceps.  A  knowledge 
of  these  features  is  of  importance,  especially  when  we  wish  to 
establish  the  diagnosis  of  fractures  and  luxations  of  this  region. 

CONSTITUENT   PARTS. 

i.  The  Skin. 

It  is  thicker  and  much  less  extensible  than  at  the  fold  of  the 
arm ;  its  surface  is  uneven,  rugous,  even  plicated  in  arcs  of  cir- 
cles in  some  subjects,  above  the  olecranon  ;  it  includes  numerous 
sebaceous  follicles  and  an  abundance  of  hairs,  in  some  male 
adults.  To  the  latter,  the  median  line  must  at  all  times  form  aji 
exception,  as  it  is  always  bare. 

n.  The  Subcutaneous  Layer. 

This  layer  is  composed  of  a  lamellated  cellular  tissue,  which  is 
very  lax  behind  the  triceps,  but  much  more  compact  upon  the 
osseous  eminences.  Below  the  articulation  this  layer  generally 
incloses  the  terminations  of  the  posterior  radial  and  posterior 
ulnar  veins ;  some  branches  of  the  musculo-cutaneus,  of  the  in- 
ternal cutaneous  and  even  of  the  radial  nerves,  also  ramify  in  it. 
Adipose  vesicles  are  more  numerous  in  it  the  further  we  remove 


300  OF   THE    THORACIC    EXTREMITIES. 

from  the  articular  eminences ;  so  that  the  fatty  tissue  may  form 
a  layer  of  a  certain  thickness  in  the  lower  part  of  the  region,  and 
another  still  thicker  in  the  superior  part,  whilst  behind  the  elbow 
properly  so  called,  fat  very  seldom  accumulates.  Upon  the 
olecranon,  the  lamella?  of  the  cellular  tissue  are  so  much  con- 
densed that  they  frequently  produce  a  complete  bursa  mucosq, 
which  is  susceptible  of  different  degrees  of  capacity,  but  in  the 
normal  state  never  contains  more  than  a  small  quantity  of  fluid. 
In  certain  diseases,  on  the  contrary,  it  sometimes  becomes  dis- 
tended with  liquid,  producing  a  tumour  of  greater  or  less  volume 
under  the  skin.  It  is  equally  subject  to  a  form  of  disease  which 
is  more  frequently  observed  in  the  synovial  membranes  of  the 
wrist ;  we  mean  the  production  of  cartilaginous  granules,  which 
may  accumulate  in  this  sac  to  the  number  of  several  hundreds. 
It  may  be  remarked  that  although  these  tumours  are  very  dan- 
gerous at  the  wrist,  they  may  be  easily  cured  at  the  elbow  ;  at 
least  we  saw,  in  1824,  at  the  Hospital  of  la  Faculte,  a  patient 
who  had  one  on  each  olecranon  process,  and  was  promptly  re- 
lieved of  them.  M .  Bougon  opened  them  extensively ;  all  the 
small  productions  were  removed,  the  cyst  inflamed,  suppuration 
followed,  and  the  cicatrization  was  completed  at  the  end  of  a 
month  without  any  accident.  As  this  tissue  is  very  moveable, 
the  divisions  of  the  skin  may  be  easily  united  by  the  first  intention. 
Even  in  wounds  with  loss  of  substance,  the  lips  of  the  solution 
are  easily  approximated,  and  the  cicatrix  is  seldom  very  extensive. 
In  consequence  of  this  laxity  also,  when  phlegmonous  erysipelas 
or  other  inflammations  supervene,  the  sub-cutaneous  layer  is  dis- 
organized with  a  great  promptitude  and  the  skin  rapidly  and 
extensively  detached. 

in.  The  Aponeurosis. 

Behind  the  tendon  of  the  triceps,  the  aponeurosis,  as  it  ap- 
proximates the  olecranon,  becomes  considerably  attenuated  ;  it  is 
transformed,  as  it  were,  into  cellular  tissue,  so  that  upon  the 
median  eminence  it  is  no  longer  met  with.  On  the  inner  side 
it  passes  to  the  epilrochlo-kumeral  intersection,  but,  previous  to 
reaching  it,  splits  in  order  to  ensheath  the  ulnar  nerve.  In  this 
direction,  it  also  becomes  thinner  as  it  descends  and  again  grows. 


OF  THE  THORACIC  EXTREMITIES.  301 

thicker  opposite  to  the  olecranon,  from  whence  it  detaches  a 
species  of  cord  which  goes  upon  the  epitrochlea ;  still  lower,  this 
fibrous  lamina  arises  from  the  posterior  ridge  of  the  ulna,  in  order 
to  pass  internally  upon  the  extensor  carpi  ulnaris  muscle.  On 
the  outer  side,  it  also  arises  from  the  triceps  tendon  at  the  epicon- 
dylo-hunieral  intersection,  unfolding  in  such  a  manner  that  one  of 
its  laminae  passes  to  the  border  of  the  bone,  and  that  between  the 
two  there  is  a  considerable  branch  derived  from  the  radial  nerve. 
Between  the  olecranon  and  the  epicondyle,  the  fibres  which 
come  from  the  triceps  intersect  those  which  proceed  from  the 
ulna,  in  order  to  pass  on  the  outer  side  of  the  fore-arm.  Finally 
the  aponeurosis  is  of  much  less  importance,  in  surgical  practice, 
in  this^ region,  than  in  the  preceding. 

iv.  The  Muscles. 

Above  the  prominences  the  triceps  exists  alone;  its  fibres 
cease  in  the  internal  groove  ;  its  external  biindle,  on  the  contrary, 
is  prolonged  to  the  posterior  part  of  the  humero-radial  articu- 
lation, where  it  is  continuous  with  the  anconeus ;  its  tendon  is 
inserted  upon  the  olecranon  in  such  a  manner  that,  in  the  flexion 
of  the  fore-arm,  it  draws  this  process  at  a  right  angle,  whilst,  in 
extension,  it  tends  to  draw  it  parallel  to  its  length:  whence  it  follows 
that  flexion  of  the  limb  backwards  would  not  be  possible,  even 
if  the  olecranon  should  not  strike  against  the  humerus.  It  should 
be  observed,  however,  that  the  tendon  is  not  inserted  into  the 
superior  surface  of  this  process,  but  into  its  posterior  part.  The 
kind  of  cord  which  seems  to  attach  the  olecranon  to  the  humerus 
during  flexion  of  the  fore-arm,  is  produced  by  the  tension  of  this 
tendon.  A  few  fibres  are  occasionally  detached  from  the  triceps 
to  be  inserted  into  the  fibrous  layer  which  covers  the  olecranoid 
cavity. 

Inferiorly,  we  find,  internally,  the  flexor  ulnaris,  the  two  origins 
of  which,  from  the  olecranon  and  epitrochlea,  are  united  by  a 
fibfbus  arch,  before  which  the  ulnar  nerve  passes;  externally, 
the  supinator  brevis,  the  origins  of  the  extensor  communis,  ex- 
tensor minimi  digiti,  extensor  ulnaris,  and  the  anconoeus.  These 
muscles  are  so  disposed  that  the  head  of  the  radius  is  almost 
naked  under  the  skin,  between  them  and  the  external  muscu- 


*  OF   THE    THORACIC    EXTREMITIES. 

lar  mass  of  the  fold  of  the  arm  ;  so  that  it  would  seem  much  more 
easy  for  luxation  of  this  bone  to  take  place  backwards  than 
forwards.  They  are,  moreover,  very  adherent  to  the  osseous 
surfaces,  a  circumstance  which  renders  their  action  of  little  effect 
in  fractures  (as  it  regards  displacement). 

v.  T/ie  Arteries. 

These  vessels  form  two  arches,  situated  in  the  two  principal 
grooves  :  the  external  is  produced  by  the  anastomoses  of  the 
posterior  radial  recurrent,  coming  from  the  interosseal,  with  the 
termination  of  the  external  collateral  of  the  arm.  It  lies  deep 
between  the  muscles,  behind  the  epicondyle  and  the  supinator 
brevis ;  it  is  occasionally  of  large  size,  so  that  a  wound  in  its  track 
might  be  attended  with  a  profuse  haemorrhage,  and  render  its 
ligature  necessary  in  the  disarticulation  of  the  fore-arm.  In  frac- 
tures of  the  epicondyle,  and  in  luxations,  it  might  be  lacerated 
and  produce  extensive  ecchymoses. 

The  internal  results  from  the  inosculations  of  the  internal  col- 
lateral with  the  posterior  ulnar  recurrent ;  its  branches  ramify  in 
the  inner  groove,  behind  the  epitrochlea,  and  anastomose  in  their 
turn  with  those  of  the  preceding,  as  well  as  with  the  anterior 
epitrochleal  arch.  In  aneurisms,  or  when  the  brachial  artery  is 
obliterated  in  any  manner  whatsoever,  these  anastomosing  arches 
sometimes  become  very  large.  It  is  in  such  cases  that  a  division 
of  the  soft  parts  in  the  region  of  the  elbow  might  be  accompanied 
with  a  troublesome  haemorrhage,  and  that,  if  we  were  obliged  to 
amputate  the  limb  very  near  the  joint,  a  great  number  of  ligatures 
would  become  necessary. 

vi.  The  Veins. 

The  deep  veins  accompany  the  arteries  and  have  the  same 
distribution.  The  superficial  vary  considerably  in  number,  and 
still  more  in  disposition.  Two  of  them  are  usually  met  wj£ : 
the  posterior  radial,  which  ascends  and  inclines  slightly  outwanfe, 
in  order  to  pass  before  the  epicondyle  and  unite  with  the  ante- 
rior radial,  forming  the  cephalic  trunk,  of  which  these  two  veins 
are  only  branches  of  origin :  the  posterior  ulnar,  which  which  i? 


OF   THE    THORACIC    EXTREMITIES.  303 

generally  larger  and  more  constant,  ascends  upon  the  flexor  ulnaris 
muscle  as  far  as  the  epitrochlea ;  then  it  passes  sometimes  behind, 
more  frequently  before  this  process,  in  order  to  unite  with  the 
basilic,  which  it  concurs  in  forming.  As  these  two  veins  are 
surrounded  by  but  few  nervous  filaments,  they  might  serve  for 
the  abstraction  of  blood ;  but  we  rarely  have  recourse  to  them , 
because  the  anterior  veins  are  always  more  distinct  and  more 
easily  opened. 

vii.  The  Lymphatics. 

We  find  no  glands  here.  The  vessels  are  few  in  number ;  the 
superficial  turn  over  the  external  and  internal  borders  in  their 
course  to  the  fold  of  the  arm ;  the  deep-seated  lymphatics  ac- 
company the  arterial  arches,  or  pass  through  the  interosseal  space, 
and  enter  the  glands  of  the  anterior  region. 

viii.  The  Nerves. 

Some  filaments,  and  the  posterior  branches  of  the  internal  cu- 
taneous and  musculo-cutaneus  nerves,  pass  or  ramify  in  the 
superficial  layers  ;  one  branch  of  the  radial  descends  behind  the 
epicondylo-humeral  intersection  (external  intermuscular  ligament), 
and  follows  the  course  of  the  arteria  profunda ;  this  branch  is 
frequently  larger  than  the  internal  cutaneous,  and  should  be 
avoided  in  cases  wherein  it  is  required  to  tie  the  arteiy.  The 
posterior  branch  of  the  radial  also  gives  off'  several  ascending 
ramuscules  below  the  articulation,  and  ramifies  principally  in  the 
superficial  muscles ;  but  the  ulnar  is  the  principal  nerve  here. 
It  lies  upon  the  epitrochlo-humeral  intersection  (internal  intermus- 
cular ligament)  between  the  aponeurotic  laminae,  it  descends  in 
the  internal  groove,  and,  behind  the  epitrochlea,  is  covered  only 
by  the  skin  and  the  aponeurosis,  so  that  it  may  be  felt  through 
the  integuments  and  may  be  easily  compressed  at  this  point  by 
the  action  of  external  agents,  as,  for  example,  when  we  strike 
the  elbow  against  the  angle  of  a  table,  etc.  It  is  this  compression 
which  gives  rise  to  the  sudden  numbness,  or  species  of  formica- 
tion, which  we  then  feel  in  the  last  two  fingers.  As  it  passes 
before  the  flexor  ulnaris  muscle  it  gives  off  some  unimportant 


301  OF    THE    THORACIC    EXTREMITIES. 

filaments  and  soon  places  itself  between  the  two  common  flexor 
muscles  of  the  fingers.  In  the  resection  of  the  inferior  humeral 
extremity,  the  ulnar  nerve  requires  some  precautions :  in  fact  it 
would  be  very  easy  to  divide  it  entirely  or  incompletely,  by  mak- 
ing the  flap  required  for  exposing  the  bone  at  the  expense  of  the 
triceps.  It  is  important,  hower,  to  preserve  it,  if  we  do  not  wish 
to  paralyze  the  last  two  fingers.  It  will  therefore  be  necessary  to 
separate  this  nerve  from  the  groove  in  which  it  is  imbedded,  and 
draw  it  before  the  epitrochlea  previous  to  making  use  of  the 
saw. 

ix.  The  Skeleton. 

The  humerus  presents  in  this  region  the  posterior  part  of  the  os- 
seous grooves  and  projections  mentioned  in  the  preceding  region. 
Above  the  articular  pulley  we  observe  a  deep  cavity,  into  which 
the  synovial  membrane  is  prolonged,  and  which  receives  the 
olecranon  when  the  fore-arm  is  extended.  It  appears  to  be 
owing  to  the  greater  or  less  depth  of  this  cavity  that  some  per- 
sons possess  the  power  of  carrying  the  fore-arm  backwards  be- 
yond the  axis  of  the  limb.  Its  bottom  is  occasionally  very  thin  : 
it  corresponds  to  the  coronoidal  depression,  and  is  sometimes 
completely  perforated.  Be  this  as  it  may,  it  is  necessary  to  re- 
mark that,  when  the  arm  is  flexed,  this  hollow  is  covered  only  by 
the  soft  parts,  the  triceps  and  the  fibrous  membrane,  which  na- 
turally conceal  it:  whence  it  follows,  that,  in  this  position,  a 
pointed  instrument  might  pass  through  it  from  behind  forwards 
and  wound  important  organs,  the  brachial  artery,  the  median 
nerve,  for  example.  The  rest  of  the  humerus  is  smooth  and 
slightly  convex ;  it  is  separated  from  the  triceps  by  a  very  sup- 
ple cellular  tissue,  which  readily  inflames  when  acute  diseases 
attack  the  articulation.  If  the  bone  was  transversely  fractured 
here,  the  inferior  fragment  would  be  thrown  backwards,  in  con- 
sequence of  the  brachialis  internus  muscle  drawing  the  superior 
end  forwards.  Oblique  fractures  easily  extend  into  the  joint, 
and  may  be  of  two  species :  either  the  solution  of  continuity  will 
be  made  from  without  inwards,  and  then  the  external  condyle 
and  the  tuberosity  which  surmounts  it  will  constitute  the  inferior 
or  external  fragment ;  or  it  may  take  place  from  within  outwards, 


OP    THE    THORACIC    EXTREMITIES.  305 

so  as  to  comprise  the  trochlea  and  epitrochlea  in  the  internal 
fragment.  In  the  first  case,  the  posterior  muscles  of  the  fore-arm 
will  tend  to  draw  the  condyle  downwards  and  backwards ;  in 
the  second,  the  trochlea  will  be  drawn  downwards  and  forwards 
by  those  of  the  anterior  part. 

The  ulna  (cubitus)  is  covered  internally  by  the  flexor  carpi 
ulnaris  muscle,  and  by  the  anconoeus,  externally ;  its  posterior 
border  is  covered  merely  by  the  skin,  and  is  connected  to  the 
humerus  by  the  internal  lateral  ligament,  which  bifurcates  as  it 
proceeds  from  the  epitrochlea,  in  order  to  attach  itself  to  the 
olecranon  and  the  coronoid  process.  The  olecranon  process  is 
one  of  the  most  essential  parts  of  the  elbow ;  as  it  is  carried  back- 
wards in  the  flexion  of  the  limb,  which  then  becomes  a  lever  of 
the  first  order,  it  elongates  the  arm  of  power,  by  separating  the 
triceps  from  the  fulcrum ;  but  in  this  position,  an  instrument 
thrust  behind  the  elbow  might  be  attended  with  great  danger, 
because  it  would  readily  penetrate  into  the  joint.  In  extension, 
this  eminence  will  not  permit  a  wound  of  this  nature,  but  will 
prevent  any  species  of  weapon  from  traversing  the  humerus  by 
the  olecranoid  cavity ;  besides,  it  will  also  oppose  an  insurmount- 
able obstacle  to  the  luxation  of  the  fore-arm  forwards,  whilst,  in 
the  first  case,  it  does  not  appear  impossible  for  an  external  cause 
to  produce  this  displacement ;  finally,  it  is  the  olecranon  which 
constitutes  the  greatest  impediment  to  the  disarticulation  of  the 
fore-arm.  Indeed,  in  this  operation,  a  large  flap  being  made  at 
the  expense  of  the  anterior  soft  parts,  the  fore-part  of  the  joint 
being  opened  by  the  division  of  the  internal,  external  and  ante- 
rior ligaments,  the  olecranon  remains,  and  forms  an  obstacle  to 
the  separation  of  the  limb.  Hence,  we  are  obliged  to  saw 
through  this  process,  which  the  triceps  will  not  fail  to  draw 
considerably  upwards ;  or  it  may  be  removed  by  sliding  the  knife 
between  it  and  the  os  brachii,  in  order  to  detach  it  from  the 
extensor  muscle  ;  but  as  the  muscle,  in  this  case,  retracts  great- 
ly, the  skin  alone  will  remain  to  form  the  posterior  flap.  We 
would  therefore  prefer  the  first  method,  if  ever  this  operation 
should  be  absolutely  necessary,  which,  however,  is  very  question- 
able. 

The  Radius  affords  nothing  very  remarkable  in  this  region : 
externally,  it  is  so  superficial  that  it  is  easy  to  recognize  its  frac- 

39 


306  OF   THE    THORACIC    EXTREMITIES. 

tures,  and  the  supinator  brevis  envelopes  it  almost  entirely.  It  is 
more  easily  luxated  backwards  than  in  any  other  direction :  on 
the  one  hand,  because  the  articulation  is  less  firmly  supported  at 
its  posterior  part ;  on  the  other,  because  the  movement  of  prona- 
tion  is  more  natural  than  that  of  supination,  and  because,  when 
this  motion  is  forced,  the  radius  tends  to  tilt  upon  the  ulna  and 
pass  behind  the  humerus.  It  is  for  this  reason  that  this  displace- 
ment is  not  rare  among  washer-women  and  those  who  are  much 
occupied  in  wringing  linen. 

The  order  of  superposition  in  the  posterior  region  of  the  elbow 
seems  to  us  too  simple  to  require  pointing  out. 

We  may  now  easily  comprehend  the  obstacles  which  oppose 
the  resection  of  the  bones  of  the  elbow ;  as  this  operation  has 
been  performed,  however,  first  by  Mr.  Park  of  Liverpool,  after- 
wards by  the  two  Moreaus  of  Bar-sur-Ornain,  and  Prof.  Roux, 
and  several  times  writh  success ;  as,  by  this  operation,  the  fore* 
arm  and  the  functions  of  the  hand  are  preserved,  the  difficulty  of 
executing  it  should  not  prevent  its  being  had  recourse  to.  Ac- 
cording to  the  method  of  the  MM.  Moreau,  the  inferior  extrem- 
ity of  the  humerus  may  be  removed  without  difficulty.  It  con- 
sists in  making  two  incisions,  one  on  each  side  of  the  bone,  and 
uniting  them  by  a  third  drawn  transversely  above  the  olecranon  ; 
it  will  then  be  necessary  to  preserve  the  ulnar  nerve,  by  dissect- 
ing it  from  its  sheath  and  carrying  it  before  the  epitrochlea,  as 
advised  by  M.  Dupuytren,  previous  to  separating,  by  means  of  a 
suitable  instrument,  the  flesh  from  the  anterior  part  of  the  articu- 
lation and  sawing  through  the  osseous  extremity.  It  is  evident 
that,  in  this  way,  the  artery  and  nerves  remaining  untouched,  the 
accidents  which  must  follow  will  be  analogous  to  those  which 
usually  accompany  extensive  wounds  ;  but  if  the  disease  requir- 
ed, at  the  same  time,  the  resection  of  the  ulna  and  radius,  the  an- 
atomical disposition  of  the  organs  induces  us  to  believe,  that,  by 
removing  these  bones  below  the  insertion  of  the  brachialis  inter- 
nus  and  biceps  muscles,  the  chances  of  success  from  the  opera- 
tion would  be  greatly  lessened,  and  the  flexion  of  the  fore-arm 
would  be  rendered  impracticable. 


OP   THE    THORACIC    EXTREMITIES.  30? 


ART.  IV.    OF    THE    FORE-ARM. 

The  fore-arm,  properly  so  called,  is  comprised  between  the 
regions  of  the  elbow  and  a  circular  line  drawn  half  an  inch 
above  the  radio-carpal  articulation.  Its  form  is  that  of  an  invert- 
ed cone,  truncated  and  flattened  upon  two  faces,  especially  infe- 
riorly.  This  form  varies  according  to  age,  embonpoint  and  the 
position  of  the  limb  ;  in  children  and  fat  persons  the  cone  is  more 
regular ;  in  emaciated  persons,  on  the  contrary,  the  fore-arm  is 
very  much  flattened,  and  nearly  as  broad  inferiorly  as  at  its  supe- 
rior part ;  in  flexion  and  pronation,  its  anterior  surface  is  more 
convex  than  in  extension  and  supination. 

In  the  latter  position,  the  fore-arm  presents  for  our  considera- 
tion a  palmar  and  a  dorsal  aspect,  a  radial  and  an  ulnar  margin. 

Sect.  1.  Anterior,  or  Palmar  Region. 

When  the  limb  is  in  the  state  of  pronation,  the  inferior  part  of 
this  region  is  directed  backwards,  its  superior  portion  inwards  : 
on  its  surface  we  observe,  superiorly,  the  continuation  of  the  two 
muscular  eminences  of  the  fold  of  the  arm,  and  the  median 
groove  which  separates  them  ;  in  the  middle,  these  two  eminen- 
ces are  almost  confounded,  and  the  groove  is  scarcely  percepti- 
ble ;  in  approximating  the  wrist,  we  see,  or  may  feel,  from  within 
outwards,  the  prominence  formed  by  the  flexor  carpi  ulnaris,  a 
groove  in  which  the  ulnar  artery  may  be  felt,  another  prominence 
formed  by  the  flexor  muscles  of  the  fingers,  a  third  by  the  tendons 
of  the  palrnaris  longus  and  flexor  carpi  radialis,  and  which  is 
much  increased  by  the  flexion  of  the  wrist  upon  the  fore-arm, 
the  fingers  being  extended ;  a  groove  broader  and  more  distinct 
than  the  first,  which  groove  may  be  considered  as  the  termination 
of  that  of  the  superior  part,  and  in  which  we  distinguish  the  radial 
artery  through  the  integuments ;  finally,  a  fourth  prominence, 
which  is  observed  on  the  outer  part  and  is  constituted  by  the 
radius.  A  considerable  number  of  vein* also  raise  the  skin,  and 
form  a  more  or  less  complicated  plexus  throughout  the  whoto 
extent  of  this  region. 


308  or    THE    TUORALIL    KXTIIEMITJ! 

CONSTITUENT  PARTS. 

i.  The  Skin. 

It  participates  in  all  the  characters  of  that  of  the  ibid  of  the 
arm  :  thus,  it  is  soft,  white,  extensible,  sometimes  covered  with 
hairs5  but  on  the  outer  and  inner  borders  only,  and  contains  a  small 
number  of  sebaceous  follicles  upon  the  median  line. 

ii.  The  Subcutaneous  Layer. 

The  same  observations  may  be  applied  to  it  as  to  the  skin ;  in 
man  it  includes  but  a  small  number  of  adipose  cells,  and  the  lam- 
ellated  tissue  which  composes  it  forms  a  layer  of  greater  or  less 
thickness,  and  always  very  moveable,  which  admits  of  the  skin 
being  readily  drawn  up  without  dissection,  when  we  amputate  in 
this  part  of  the  fore-arm,  etc.  In  childhood  and  in  the  female,  an 
abundance  of  adipose  vesicles  is  sometimes  developed  in  it ;  it  is 
then  of  greater  thickness,  and  it  is  this  adipo-cellular  layer  which 
gives  to  the  fore-arm  that  cylindrical  form  which  is  peculiar  to 
the  female  sex.  As  this  tissue  incloses  the  veins,  these  vessels 
are  always  more  distinct  in  man  than  in  woman.  It  is  this  layer 
also  which  is  the  seat  of  the  principal  disorders  in  phlegmonous 
erysipelas  ;  and  as  it  is  not  firmly  adherent  either  to  the  aponeuro- 
sis  or  skin,  it  is  necessary  to  evacute  promptly  the  diseased  fluids 
which  may  have  accumulated  in  its  lamella?,  if  we  wish  to  avoid 
the  detachment  of  the  cutaneous  envelope. 

in.  The  Aponeurosis. 

If  we  commence  with  this  membrane  at  the  posterior  border 
of  the  ulna  and  trace  it  to  the  anterior  margin  of  the  radius,  we 
will  find  that  it  has  not  exactly  the  same  arrangement  throughout 
the  whole  extent  of  the  region.  In  departing  from  the  bone, 
superiorly,  it  passes  ov^r  the  anterior  face  of  the  flexor  carpi 
ulnaris  muscle  ;  between  this  bundle  and  the  flexor  sublimis,  the 
aponeurosis  sends  off  a  sheet  which  passes  inwards  before  the 
flexor  profundus  and  from  thence  to  the  ulna,  completing  the 


OP    THE    THORACIC    EXTREMITIES.  IlOi 

sheath  of  the  flexor  ulnaris  muscle :  the  place  at  which  this  sheet 
is  detached  is  always  marked  by  a  distinct  line,  which  directs  us 
in  finding  the  ulnar  artery.  The  aponeurosis  is  afterwards  con- 
tinued over  the  anterior  surface  of  the  muscles ;  when  it  gets 
near  the  supinator  longus  it  splits,  and  its  superficial  lamina  passes 
before  this  muscle,  whilst  the  deep-seated  passes  behind  it  and 
forms,  on  its  part,  a  small  sheath  for  the  radial  artery :  beyond 
the  supinator,  these  two  laminae  approximate  and  become 
blended  with  the  aponeurosis  of  the  posterior  region.  Inferiorly, 
the  two  sheets  which  envelope  the  flexor  ulnaris,  become  con- 
joined before  they  attach  themselves  to  the  ulna ;  and  the  same 
takes  place  with  respect  to  those  of  the  supinator  longus  previous 
to  their  insertion  into  the  radius;  so  that  between  these  two 
muscles,  the  aponeurosis  binds  down  all  the  other  tendinous  and 
muscular  organs,  and  no  longer  forms  but  a  single  lamina.  It 
must  be  observed  also  that  a  third  very  thin  sheet  passes  from 
the  anterior  margin  of  the  ulna  before  the  flexor  profundus,  and 
that  it  is  upon  this  that  the  ulnar  artery  lies ;  so  that,  in  order  to 
expose  this  vessel,  two  fibrous  laminae  must  be  divided ;  whereas, 
but  one  only  is  met  with  before  the  radial. 

The  most  of  the  fibres  of  the  anti-brae hial  aponeurosis  are 
transversal ;  superiorly,  they  give  attachment  to  the  fleshy  fibres ; 
inferiorly,  the  expansion  which  they  form  has  no  adhesion  with 
the  muscles. 

iv.  The  Muscles. 

They  are  numerous  and  form  two  strata :  the  first,  taken  in 
the  direction  from  within  outwards,  comprises  the  flexor  carpi 
ulnaris,  flexor  minimi  digiti,  flexor  sublimis,  palmaris  longus, 
flexor  carpi  radialis,  and  pronator  teres ;  the  second,  the  flexor 
profundus,  flexor  longus  pollicis,  and  pronator  quadratus  ;  finally, 
upon  the  fore  part  of  the  radius  we  observe,  superiorly,  the  ter- 
mination of  the  pronator  teres  and  of  the  supinator  brevis,  the 
extensor  radialis  longior  and  brevior,  and  the  supinator  longu?. 
It  is  between  these  two  layers  that  the  principal  nerves  and  ves- 
sels are  situated.  The  flexor  carpi  ulnaris  and  sublimis  separate 
as  they  descend,  and  give  rise  to  the  internal  gutter :  the  ulnar 
artery  corresponds  to  this  interval ;  the  supinator  longus  and  the 
flexor  carpi  radialis  also  separate,  in  order  to  form  the  external 


310  OF   THE   THORACIC    EXTREMITIES. 

gutter  which  includes  the  radial  artery.  The  extensores  radialis 
longior  et  brevior  turn  outwards  and  pass  into  the  posterior  re- 
gion. The  origin  of  the  flexor  profundus  is  prolonged  as  far  as 
just  below  the  coronoid  process,  and  is  also  attached  to  the  radius 
below  the  bicipital  tubercle :  it  is  above  the  species  of  arch 
which  it  forms  superiorly,  that  the  interosseous  artery  insinuates 
itself  before  the  interosseous  ligament ;  the  flexor  longus  pollicis 
rests  upon  the  fore  part  of  the  radius,  and  receives  a  small 
rounded  bundle  from  the  coronoid  process ;  the  anterior  interos- 
seous artery  and  nerve  lie  in  the  bottom  of  the  interstice  which 
separates  these  two  muscles.  The  pronator  quadratus,  from  its 
transverse  direction,  constantly  tends  to  approximate  the  two 
inferior  fragments  of  the  bones  when  fractured. 

The  superior  portion  of  all  these  organs  is  entirely  fleshy, 
whilst  inferiorly  the  fibrous  element  predominates.  The  tendons 
of  these  muscles,  at  first  more  or  less  blended  with  one  another, 
afterwards  separate  ;  but,  nevertheless,  they  are  always  con- 
nected by  a  species  of  fibro-cellular  or  synovial  membrane,  the 
arrangement  of  which  is  very  complicated,  and  its  inflammations 
extremely  dangerous;  whence  it  follows  that  wounds  of  the 
superior  part  of  the  fore-arm  must  be  attended  with  less  for- 
midable symptoms  than  those  of  its  inferior  portion. 

v.  The  Arteries, 

All  the  arteries  of  this  region  are  derived  from  the  brachial. 
The  first  is  the  radial,  which  descends  parallel  to  the  direction  of 
the  radius,  covered  anteriorly  and  in  its  superior  half  by  the 
internal  border  of  the  supinator  longus  and  the  two  lamina?  of 
the  aponeurosis ;  in  the  other  half  the  aponeurosis  alone  is  before 
the  artery,  and  its  two  laminae  are  usually  reunited.  The  radial 
rests,  from  above  downwards,  upon  the  tendons  of  the  supinator 
brevis,  pronator  teres,  then  upon  the  radius :  a  cellular  lamina 
separates  it  from  these  parts  and  from  the  pronator  quadratus, 
which  is  more  inferiorly.  On  its  outer  side  we  see,  first,  the  ex- 
tensores radialis  longior  et  brevior  and  the  supinator  longus 
muscles,  afterwards  the  tendon  of  the  latter  only.  The  radial 
nerve  lies  upon  this  side  also,  but  it  is  always  a  line  at  least  dis- 
tant from  this  vessel ;  so  that  it  may  be  easily  avoided  when 
applying  a  ligature  upon  the  artery.  The  flexor  longus  pollicis 


OF   THE    THORACIC    EXTREMITIES.  311 

and  flexor  carpi  radialis  run  along  its  internal  surface ;  more  im- 
mediately, this  artery  is  enveloped  by  a  cellular  sheath,  which 
also  contains  its  two  venae  comites.  From  these  anatomical 
relations,  it  follows  that  the  radial  artery  becomes  more  super- 
ficial in  proportion  as  it  approximates  the  carpus,  and  that,  in 
order  to  find  it,  we  may  have  recourse  to  three  different  me- 
thods almost  equally  certain.  Thus,  by  making  an  incision  in  the 
direction  of  a  line  drawn  from  the  middle  of  the  space  which 
separates  the  condyles  of  the  humerus  and  terminating  on  the 
inner  side  of  the  styloid  process,  we  are  certain  of  falling  upon 
the  artery  ;  when  the  radial  gutter  is  distinct,  we  might  make  use 
of  it  in  the  same  manner :  lastly,  after  the  integuments  have 
been  divided,  we  will  always  find  it  between  the  flexor  carpi 
radialis  and  supinator  longus.  By  attempting  to  discover  it 
according  to  these  methods,  the  skin  being  divided,  the  median 
vein  will  frequently  present  itself  in  the  direction  of  the  wound ; 
it  should  be  pushed  inwards,  and  we  will  always  avoid  mistaking 
it  for  the  artery,  if  we  recollect  that  the  aponeurosis  separates 
these  two  vessels ;  a  grooved  director  is  then  to  be  insinuated 
under  this  fascia,  upon  which  the  bistoury  is  to  be  introduced  for 
the  purpose  of  incising  it,  when,  if  we  operate  inferiorly,  the 
artery  will  be  exposed ;  if  higher  up,  the  margin  of  the  supi- 
nator must  be  pressed  outwrards,  when  we  will  see  the  artery, 
surrounded  by  its  vena3  comites,  through  a  second  fibrous  lamina 
which  should  be  divided  also,  in  order  that  the  aneurismal  needle 
may  be  passed  behind  it,  which,  as  there  is  no  essential  organ  in 
its  immediate  vicinity,  may  be  introduced  on  either  side.  The 
nerve  is  sufficiently  remote  on  its  outer  side  to  be  always  avoided. 
The  radial  artery  is  sometimes  subcutaneous,  and  this  anomaly 
might  re,nder  very  superficial  wounds  dangerous.  In  such  a  case? 
its  pulsations  are  usually  perceived  through  the  skin ;  but  if  the 
limb  is  engorged  or  tumefied,  in  any  manner  whatsoever,  and  an 
incision  is  required  to  be  made  upon  it  in  the  course  which  this 
artery  then  takes,  we  can  conceive  the  accidents  which  might 
result  from  it.  At  other  times  it  changes  its  direction,  and  about 
the  middle  of  the  fore-arm  turns  over  the  outer  side  of  the  radius. 
This  anatomical  variety  is  one  of  the  most  frequent,  and  requires 
special  notice,  for  it  might  lead  to  a  deception  with  respect  to 
the  nature  of  the  pulse  in  diseases,  if,  as  frequently  happens, 
a  branch  of  a  certain  calibre  supplied  the  place  of  the  trunk :  it 


312  OF    THE    TI1UUACIC    EXTREMITIES. 

might  also  cause  a  profuse  haemorrhage  in  a  simple  wound  of  the 
external  part  of  the  fore-arm.  The  first  disposition  generally 
depends  upon  the  high  division  of  the  brachial  artery  ;  and  the 
second,  upon  the  small  dorsal  branch  of  the  radial  having  acquired 
a  greater  volume  than  usual. 

The  Ulnar  comes  next,  forming  as  it  descends  a  gentle  but 
very  long  curvature,  with  external  convexity.     It  is  at  first  si- 
tuated between  the  superficial  muscular  stratum  and  the  flexor 
profundus,  and  in  the  anti-brachial  region  is  found  in  relation 
with  the  following  organs  ; — anteriorly  and  externally,  the  flexor 
sublimis  ;  posteriorly,  the  profundus  ;  internally,  the  flexor  carpi 
ulnaris,  the  tendon  of  which  lies  more  or  less  over  it ;  inferiorly, 
more  immediately,  we  see  upon  its  external  side  its  collateral 
vein  or  veins  :  the  ulnar  nerve  touches  it  upon  the  internal  side. 
It  is,  consequently,  very  deep  superiorly,  and  very  difficult  of 
access.     If,  however,  we  wish  to  expose  it,  we  must  divide  the 
integuments  in  the  direction  of  a  line  which  would  commence  at 
the  inner  part  of  the  trochlea  in  order  to  descend  perpendicularly 
upon  the  external  side  of  the  os  pisiforme ;  next  we  would  seek 
for  the  fibrous  line  which  separates  the  flexor  carpi  ulnaris  from 
the  flexor  sublimis,  and  which  is  always  the  first  which  is  met 
with  in  proceeding  from  the  posterior  border  of  the  ulna.     The 
aponeurosis  being  cut  through  upon  this  line,  the  muscles  will  be 
easily  separated  ;  the  nerve  will  soon  be  discovered  at  the  bottom 
of  the  wound,  upon  the  flexor  profundus,  and  then,  by  placing  the 
extremity  of  the  needle  upon  the  external  side  of  this  nerve,  it 
will  be  sufficient  to  dip  this  instrument  a  little  and  afterwards 
raise  it  outwards,  in  order  to  seize  the  artery,  which  is,  in  fact, 
almost  always  placed  in  the  latter  direction,  and  a  little  forwards  ; 
but  it  is  necessary  to  observe  that  these  relations  exist  only  in  the 
four  inferior  fifths  of  the  fore-arm  ;  for  in  the  superior  fifth,  as  the 
artery  runs  obliquely  outwards  and  upwards,  it  becomes  more 
and  more  remote  from  the  ulnar  nerve.     Inferiorly,  after  having 
divided  the  skin  and  cellular  layer,  we  must  cut  the  first  lamina 
of  the  aponeurosis  upon  the  internal  margin  of  the  tendon  of  the 
flexor  carpi  ulnaris  muscle ;  then  by  pushing  this  tendon  in  ward  s 
we  will  see  the  artery  through  a  second  fibrous  lamina,  in  general 
of  considerable  strength,  which  binds  it  down  upon  the  inner  part 
of  the  flexor  profundus ;  its  relations  are,  otherwise,  the  same  as 
in  the  rest  of  its  extent. 


OF    THE    THORACIC    EXTREMITIES.  313 

This  artery  is  sometimes  superficial,  so  that  its  pulsations  are 
visible  through  the  skin.  In  other  cases,  it  does  not  approximate 
the  nerve  until  very  near  its  inferior  part;  it  would  then  be 
difficult  to  apply  a  ligature  around  it. 

Finally,  the  Interosseal  divides  at  the  point  of  union  of  the  flexor 
profundus  and  flexor  longus  pollicis,  and  the  interosseal  branch, 
properly  so  called,  rests  upon  the  anterior  surface  of  the  interos- 
seous  ligament,  which  it  passes  through  at  the  upper  part  of  the 
pronator  quadratus.  It  is  for  the  purpose  of  seizing  this  branch 
the  more  readily  that,  in  amputating  the  fore-arm,  we  are  advised 
to  cut  through  the  ligament  which  supports  it. 

From  what  has  preceded,  we  see  that  the  ulnar  artery  is  not 
susceptible  of  being  firmly  compressed,  whilst  the  radial,  on 
the  contrary,  may  be  obliterated  by  pressing  it  against  the  radius, 
in  its  inferior  half.  All  the  other  branches  are  too  small  to  de- 
serve any  attention  in  operations. 

vi.  The  Veins. 

The  superficial  veins  form  a  very  complicated  net-work  under 
the  skin ;  they  communicate  with  each  other  a  great  number  of 
times,  and  vary  greatly  both  in  number  and  disposition.  The 
most  constant  and  largest  are  the  vena  ulnaris  anterior,  the  me- 
diana,  and  radialis  cutanea  anterior.  The  first  receives  the  most 
of  the  veins  of  the  hypothenar  eminence,*  and  ascends  along 
the  ulnar  side  of  the  region  in  order  to  constitute,  upon  the  inter- 
nal muscular  mass  of  the  fold  of  the  arm,  one  of  the  roots  of 
the  basilic.  It  is  sometimes  so  large  that  blood  may  be  drawn 
from  it,  when  this  operation  cannot  be  performed  elsewhere.  It 
is  accompanied  by  the  anterior  twigs  of  the  internal  cutaneous 
nerve. 

The  second  arises  principally  in  the  palm  of  the  hand ;  in  as- 
cending it  follows  the  radial  groove,  and  in  this  manner  gradu- 
ally inclines  towards  the  median  line  of  the  limb,  until  it  reaches 

*  The  os  metacarpi  pollicis  is  surrounded  by  a  considerable  muscular  mass  con- 
sisting of  four  muscles,  the  abductor  brevis  pollicis,  opponens  pollicis,  flexor  brevis 
pollicis,  and  abductor  pollicis,  these  constitute  the  thenar  eminence  :  the  hypothenar 
eminence  is  formed  by  the  muscles  surrounding  the  os  metacarpi  minimi  digiti,— 
Transl. 

40 


314  OF    TllE    THORACIC    EXTREMITIES. 

the  anterior  region  of  the  elbow,  where  we  have  already  exam- 
ined it :  this  is  usually  the  most  voluminous  of  the  three,  and 
therefore  that  which  may  be  opened  most  readily,  if  we  cannot 
perform  venesection  in  the  ordinary  situation.  It  must  then  be 
kept  in  mind,  that  this  vein  is  accompanied  by  a  considerable 
branch  of  the  musculo-cutaneus  nerve,  which  generally  lies 
upon  the  external  side  of  the  vessel. 

The  third  is  one  of  the  principal  roots  of  the  cephalic ;  it  comes 
from  the  thenar  eminence*  and  thumb,  and  does  not  usually  enter 
the  anterior  anti-brachial  until  it  arrives  near  its  middle  ;  it  places 
itself  externally  and  upon  the  anterior  face  of  the  external  mus- 
cular eminence,  and  afterwards  inclines  more  or  less  backwards 
in  order  to  unite  with  the  posterior  radial  and  form  the  cephalic. 
This  is  the  most  variable,  and  that  which  is  most  frequently  want- 
ing ;  it  is  only  surrounded  by  some  very  delicate  filaments  of  the 
musculo-cutaneus  nerve. 

All  these  veins,  like  those  of  the  fold  of  the  arm,  are  here  en- 
veloped in  the  deep  plates  of  the  superficial  layer,  and,  in  this 
respect,  we  may  apply  to  them  the  same  surgical  considerations. 
The  median  generally  follows  the  track  of  the  radial  artery ;  where- 
by, when  we  attempt  to  tie  the  latter,  we  are  frequently  embar- 
rassed by  the  vein,  which  must  be  pushed  outwards  or  inwards, 
as  may  be  most  convenient.  The  ulnar  does  not  follow  the  ar- 
tery of  the  same  name  so  exactly ;  so  that,  when  we  wish  to  ex- 
pose the  latter  vessel,  we  are  seldom  obliged  to  separate  the  vein. 

They  are  scarcely  distinct  in  women  and  children,  on  account 
of  the  thickness  of  the  adipose  layer  ;  but  in  the  adult  male,  old 
people,  and  especially  those  who  exercise  the  hands  and  thoracic 
limbs  vigorously,  their  calibre  is  generally  much  greater ;  which 
is  undoubtedly  owing  to  the  profuse  supply  of  blood  attracted  to 
these  extremities  by  the  muscular  action,  which  not  being  able 
to  ascend  in  the  same  quantity  by  the  deep-seated  veins  is  obliged 
to  pass  into  the  superficial. 

The  deep-seated  veins  are  disposed  like  the  arteries,  and  are 
occasionally  double.  The  two  radials  are  situated  on  each  side 
of  the  artery  and  communicate  with  each  other  before  it,  at  cer- 
tain intervals.  We  less  frequently  meet  with  a  duplicate  of  the 
ulnar  and  mterosseal  veins.  All  these  veins  should  be  cautiously 

*  See  Note,  page  313. 


OF   THE    THORACIC    EXTREMITIES.  315 

avoided  when  we  tie  one  of  the  accompanying  arteries ;  not 
from  fear  of  impeding  the  circulation,  but  because  experience  has 
proved  that  they  readily  inflame  when  comprised  in  a  ligature, 
and  every  body  knows  that  inflammation  of  the  veins  is  dan- 
gerous. 

vn.  The  Lymphatics. 

The  superficial  are  very  large  and  numerous ;  they  wind  around 
the  principal  veins,  and  throughout  the  whole  extent  of  the  cel- 
Julo-adipose  layer.  The  deep-seated  form  two  remarkable  clusters 
around  the  radial  and  ulnar  vessels,  and  a  third,  less  constant,  or 
less  distinct,  which  accompanies  the  interosseous  artery. 

Generally  there  are  no  glands  in  the  anterior  region  of  the 
fore- arm ;  however,  we  have  met  with  one,  two,  and  even  three 
in  the  track  of  the  radial  artery,  but  they  were  always  very  small, 
lenticular,  or  hordiforme.  We  may  admit  that  these  organs,  in 
consequence  of  some  morbid  virus,  are  susceptible  of  acquiring 
a  certain  volume,  and  of  producing  tumours  the  nature  of  which 
might  easily  be  misunderstood.  Finally,  the  abundance  of  the 
lymphatics  upon  the  palmar  aspect  of  the  fore-arm,  added  to  the 
delicate  structure  of  the  integuments,  is  the  principal  anatomical 
reason  for  preferring  the  application  of  medicaments  upon  it 
which  we  intend  to  administer  by  absorption. 

viii.  The  Nerves. 

In  speaking  of  the  veins  we  pointed  out  the  superficial  nerves : 
they  appertain  to  the  internal  cutaneous  and  musculo-cutaneus, 
the  anterior  branches  of  which  are  almost  entirely  lost  in  this 
region,  after  having  ramified  a  great  many  times  in  the  cellular 
layer.  Their  filaments  ultimately  terminate  in  the  skin. 

The  deep-seated  nerves  appertain  to  the  radial,  ulnar  and 
median. 

The  first  (radial)  follows  the  external  side  of  the  artery,  but 
leaves  it  inferiorly,  turning  outwards  in  order  to  pass  between 
the  radius  and  the  tendon  of  the  supinator  longus ;  so  that  this 
nerve  runs  no  risk  of  being  included  in  the  ligature  of  the  radial 
artery  at  the  inferior  fourth  of  the  fore-arm ;  whilst  above  this, 


316  OF   THE    THORACIC    EXTREMITIES. 

these  two  organs  lie  so  close  to  each  other  that  it  is  better,  if  not 
indispensable,  to  introduce  the  grooved  director  under  the  artery 
from  the  radial  towards  the  cubital  side :  a  wound  of  it  would 
impair  more  or  less  the  action  of  the  first  three  fingers. 

The  second  (ulnar)  follows  the  direction  of  the  line  indicated 
when  speaking  of  the  ulnar  artery,  and  runs  along  its  internal 
side ;  it  is  only  about  three  inches  below  the  epitrochlea  that  it 
touches,  as  it  were,  this  vessel ;  above  this,  it  is  separated  from 
it  by  a  triangle  with  its  base  uppermost,  the  external  side  of  which 
is  represented  by  an  oblique  line  drawn  from  the  tendon  of  the 
biceps  to  four  fingers'  breadth  below  the  articulation,  and  in  which 
we  find  the  internal  muscular  eminence,  a  portion  of  the  ulna, 
etc.  Near  the  wrist,  the  ulnar  nerve  sends  its  posterior  branch 
behind  the  carpus,  and  the  anterior  retains  the  same  relations 
with  the  artery  as  the  trunk.  From  its  position,  this  nerve  could 
not  be  divided  by  a  cutting  instrument  drawn  across  the  fore- 
arm without  the  artery  being  equally  wounded ;  so  that  in  a 
wound  of  this  nature,  the  paralysis  of  the  last  two  fingers  would 
be  sufficient  to  induce  us  to  infer  that  the  ulnar  artery  is  divided. 

The  third,  or  median  nerve,  descends  perpendicularly  between 
the  two  flexor  muscles  of  the  fingers,  and  like  them  is  found  en- 
veloped, near  the  carpus,  in  a  very  dense  and  very  extensible 
fibro-cellular  membrane  ;  it  is  situated  nearly  upon  the  median 
line  ;  the  only  branch  which  it  gives  off,  inferiorly,  is  the  palma- 
ris  cutaneus  ;  this,  however,  is  not  constant.  The  interosseous 
is  also  derived  from  the  median :  it  follows  the  artery  of  the 
same  name,  is  always  situated  on  the  outer  side  of  it,  and  is  some- 
times  so  adherent  to  it  that  it  is  difficult  to  separate  them  :  a  cir- 
cumstance which  should  not  be  forgotten  in  amputations,  when 
we  are  securing  the  arteries. 

The  other  nervous  filaments  of  this  region  are  distributed  to 
the  muscles,  and  are  of  no  importance  in  surgery. 

ix.  The  Skeleton. 

It  is  represented  by  the  anterior  faces  of  the  ulna,  radius  and 
interosseous  ligament.  This  surface  forms  a  concavity,  the  deep- 
est part  of  which  corresponds  to  the  middle  of  the  fore-arm :  the 
muscles  cover  it  entirely,  with  the  exception  of  the  anterior  and 


OF   THE   THORACIC    EXTREMITIES.  317 

inferior  third  of  the  radius,  which  is  subcutaneous.  These  bones, 
however,  will  be  described  more  particularly  in  the  following  re- 
gion. 

Sect.  2.  Posterior  Anti-Brachial  Region. 

This  region  is  more  regularly  convex  than  the  preceding ;  it  is 
more  unequal,  and  its  muscles  are  more  distinctly  delineated. 
The  principal  features  which  we  observe  upon  its  surface  are, 
from  within  outwards  ;  1st,  an  elongated  prominence  which  cor- 
responds to  the  ulna  and  the  extensor  carpi  ulnaris  muscle  ;  3d, 
a  groove,  scarcely  distinct  superiorly,  much  broader  and  more 
apparent  inferiorly ',  3d,  another  prominence,  formed  by  the  fleshy 
portion  of  the  extensor  digitorum  communis  ;  4th,  a  second  groove 
which  separates,  superiorly,  the  latter  eminence  from  that  which 
is  formed  by  the  extensor  radial  muscles,  and  which  turns  before 
and  above  the  extensor  muscles  and  abductor  pollicis  longus ;  5th 
and  lastly,  a  third  relief  which  corresponds  to  the  latter  muscles. 

CONSTITUENT   PARTS. 

i.  The  Skin. 

It  is  of  considerable  thickness,  is  shaded  by  numerous  hairs, 
and  contains  many  sebaceous  follicles.  Its  surface  is  irregular, 
rough  in  thin  subjects,  in  certain  diseases,  and  upon  a  sudden  im- 
pression of  cold ;  it  is  less  vascular  than  upon  the  palmar  surface, 
though  pretty  extensible.  Solar  spots  or  freckles  are  as  fre- 
quently observed  here  as  upon  the  rest  of  the  limb,  especially  in 
those  of  a  fair  complexion.  , 

ii.  The  Subcutaneous  Layer. 

This  layer  is  generally  thinner  than  in  the  anterior  region,  and 
contains  a  smaller  number  of  adipose  vesicles ;  on  the  other  hand, 
it  has  greater  suppleness  and  extensibility,  but  is  less  adherent  to 
the  strata  between  which  it  is  placed. 


318  OF  THE    THORACIC    EXTREMITIES. 


in.  The  Aponeurosis. 

It  is  blended  with  the  anterior  portion  of  the  anti-braciimi 
aponeurosis  upon  the  posterior  margin  of  the  ulna :  opposite  to 
the  external  border  of  the  extensor  carpi  ulnaris  a  process,  or 
species  of  intersection,  is  reflected  from  it  to  the  bone,  forming  a 
sheath  for  this  muscle  ;  then  it  furnishes,  in  the  same  manner, 
another  sheath  for  the  tendon  of  the  extensor  minimi  digiti,  after- 
wards a  third  to  the  extensor  digitorum  communis.  Finally,  the 
abductor  pollicis  longus  (extensor  primi  internodii  pollicis),  and 
the  extensores  longus  et  brevis  pollicis  (extensores  tertiiet  secundi 
internodii  pollicis),  are  equally  enveloped  by  it,  when  they  turn 
upon  the  radius.  Above  and  below  these  last,  the  aponeurosis 
attaches  itself  to  the  posterior  border  of  this  bone ;  it  receives  a 
lamina  which  separates  the  two  muscular  layers,  and  is  continu- 
ous with  the  sheets  which  enclose  the  supinator  longus,  the  radi- 
ales  (extensores),  etc.  From  this  arrangement  it  follows,  that  each 
of  the  dorsal  muscles  of  the  fore-arm  is  enclosed  in  a  species  of 
fibrous  canal  inferiorly,  and  that  superiorly,  they  are  only  sepa- 
rated by  intersections  which  are  in  general  very  solid :  this  per- 
fectly coincides  with  their  functions,  since  their  fixed  point  is  tho 
same,  or  nearly  so,  for  all,  whilst  the  moveable  extremity  of  each 
must  act  independently  under  a  multiplicity  of  circumstances. 
It  should  also  be  observed  that  these  septa  of  the  aponeurosis,  by 
being  fixed  from  space  to  space  upon  the  bones,  must  give  to  it 
greater  strength  and  resistance,  and  that  the  muscles,  more  firmly 
supported,  acquire,  in  contracting,  an  energy  which  they  would 
not  have  possessed  if  they  had  been  loosely  applied  upon  the  skel- 
eton. 

iv.  The  Muscles. 

They  form  two  very  distinct  strata :  the  superficial  comprises, 
in  examining  them  from  the  radius  towards  the  ulna,  the  extensor 
communis,  extensor  minimi  digiti,  extensor  carpi  ulnaris  and  the 
ancona3us  (epicondylo-cubital). 

The  first  (extensor  communis)  lies,  superiorly,  immediately  upon 
the  bones  and  the  interosseous  ligament ;  then  upon  the  deep 


OF    THE    THORACIC    EXTREMITIES.  319 

muscular  layer  ;  externally  and  internally,  it  is  confounded  with 
the  radial  extensors  and  extensor  carpi  ulnaris  ;  directly  behind,  it 
is  covered  by  the  aponeurosis :  as  it  descends,  it  divides  into  two 
bundles,  in  one  of  which  we  distinguish  the  origin  of  the  tendons 
which  pass  to  the  indicator  and  little  fingers  ;  in  the  other,  those 
which  go  to  the  middle  and  ring  fingers ;  whence  it  follows,  that, 
the  hand  being  shut,  it  is  not  possible  to  extend  the  annular  finger 
completely  without  the  medius,  whilst  we  may  very  readily  extend 
the  indicator  or  little  finger  separately.  The  whole  of  its  tendi- 
nous portion  is  enveloped  in  a  species  of  fibro-cellular  membrane, 
or  synovial  bursa,  which  favours  its  movements,  and  in  which  we 
sometimes  meet  with  very  soft  and  very  large  fatty  vesicles,  simi- 
lar to  those  situated  within  the  orbit. 

The  second  (extensor  minimi  digiti)  is  in  fact  only  a  fastis  giv- 
en off  from  the  former  at  a  greater  or  less  elevation,  and  only 
merits  particular  mention  because  it  is  enveloped  in  a  distinct 
sheath,  which  permits  it  to  act  independently  of  the  tendons  of 
the  extensor  com  munis  ;  therefore  we  may  easily  extend  the  little 
finger  whilst  the  others  are  in  a  state  of  flexion. 

The  third  (extensor  carpi  ulnaris)  is  disposed,  inferiorly,  in  such 
a  manner  that  its  tendon  lies  very  superficial ;  whence  it  is  very 
much  exposed  to  the  action  of  foreign  bodies,  and  is  frequently  di- 
vided by  transverse  wounds  inflicted  upon  the  inner  border  of  the 
fore-arm. 

The  fourth  (anconceus)  seems  to  be  only  a  prolongation  of  the 
triceps  extensor ;  its  uses  are  of  but  slight*  importance,  and,  in  a 
surgical  point  of  view,  it  presents  nothing  worthy  of  much 
attention. 

The  deep-seated  layer  contains,  from  within  outwards,  the 
extensor  indicis,  the  short  and  long  extensors  of  the  thumb,  and 
its  long  abductor ;  the  tendons  of  the  radials  (extensors)  are  also 
partly  found  in  it.  All  these  muscles,  imbricated  upon  one  an- 
other, pass  obliquely  outwards  and  downwards,  so  that  the  tendon 
of  the  indicator  does  not  actually  separate  from  those  of  the  ex- 
tensor comnmnis  until  it  reaches  the  wrist.  It  is  the  same  with 
the  extensor  longus  pollicis  (extensoi*  tertii  internodii),  which  is 
situated  a  little  more  externally;  but  the  extensor  brevis  (extensor 
secundi  intem.odii)  and  abductor  longus  pollicis  (extensor  primi 
intcrnodii)  make  a  partial  spiral  turn,  extending  from  the  poste- 


320  OF   THE    THORACIC    EXTREMITIES. 

rior  aspect  of  the  interosseus  ligament  and  radius  to  the  root  of 
the  thenar  eminence ;  from  which  circumstance  these  muscles 
are  supinators  of  the  thumb  and  hand,  at  the  same  time  that  they 
are  extensors  and  abductors.  The  aponeurosis  furnishes  for  them 
a  fibrous  case,  which  is  stronger  and  more  compact  the  nearer  it 
approaches  the  wrist.  In  this  canal,  the  tendons  are  applied 
upon  one  another,,  and  that  of  the  short  extensor  is  behind. 
Their  surface  is  smooth  and  covered  with  a  synovial  membrane, 
which  also  lines  the  interior  of  their  sheath,  and  sometimes  they 
are  separated  by  a  thin  septum,  which  divides  this  sheath  into 
two.  This  theca,  or  the  organs  it  encloses,  is  occasionally  the 
seat  of  a  very  singular  disease,  which  we  have  met  with  in  ten  or 
twelve  persons,  although  it  is  not  generally  mentioned  in  works 
on  surgery.  We  see  occurring,  without  any  known  cause,  or  in 
consequence  of  some  effort,  a  swelling,  which  never  becomes 
very  considerable,  throughout  the  whole  track  of  the  muscles 
just  mentioned  :  this  swelling  is  accompanied  with  heat  and  pain, 
which  are  not  usually  very  great,  unless  the  patient  endeavours  to 
move  the  thumb ;  but  what  is  most  singular,  is  that,  if  we  grasp 
the  tumid  part  with  one  hand  and  move  the  thumb  with  the  other, 
we  feel  and  hear  a  very  distinct  crepitus,  so  much  so  that  we 
have  known  a  surgeon,  in  a  similar  case,  pronounce  it  to  be  a 
fracture  and  apply  a  bandage.  This  affection,  in  those  in  whom 
we  have  observed  it,  always  disappeared  at  the  end  of  fifteen 
days  or  a  month,  without  any  one  particular  method  of  treating 
it  seeming  to  be  attended  with  more  benefit  than  another.  Al- 
though leeches,  cataplasms,  spirits  of  camphor,  ammoniated  lini- 
ments, or  other  discutients  were  applied,  and  cornpressive  ban- 
dages or  rest  had  recourse  to,  it  could  not  be  ascertained  which 
of  these  means  actually  deserved  the  preference,  and  we  think 
that  its  appropriate  remedy  is  yet  to  be  discovered. 

The  tendons  of  the  external  (extensor)  radials  slide  between 
the  preceding  muscles  and  the  posterior  surface  of  the  radius ; 
they  soon  enter,  in  their  turn,  into  a  fibrous  canal  not  so  strong 
as  the  preceding,  and  in  which  they  are  separated  by  a  septum 
which  is  sometimes  wanting :  the  radial  nerve  turns  over  the 
bone  between  these  latter  tendons,  the  supinator  and  the  abductor 
longus  and  extensor  brevis  pollicis  muscles. 


OF    THE    THORACIC    EXTREMITIES.  321 


v.  The  Arteries. 

The  Interosseous  arteries  are  the  only  ones  observed  in  this 
region.  The  posterior,  after  having  given  off  the  recurrens 
ulnaris,  ramifies  in  the  superficial  muscular  stratum,  and  descends 
almost  to  the  wrist.  It  is  so  large  as  to  require  a  ligature  after 
amputations.  The  anterior  interosseal  does  not  enter  the  dorsal 
portion  of  the  fore-arm  until  near  its  inferior  fourth  part ;  it 
remains  applied  upon  the  bones,  and  is  so  small  that  it  seldom 
presents  any  particular  indications.  The  posterior  branch  of  the 
artery  also  enters  this  region  about  an  inch  or  two  above  the  infe- 
rior extremity  of  the  ulna,  and  it  is  not  uncommon  to  see  it  of 
the  size  of  a  crow-quill.  In  the  preceding  region,  we  stated  that 
the  radial  and  ulnar  arteries  might  likewise  pass  behind  the  fore- 
arm by  anomaly,  etc. .  As,  in  these  cases,  they  are  always  very 
superficial,  they  will  then  render  the  solutions  of  continuity  more 
dangerous. 

vi.  The  Veins. 

The  posterior  radial  and  ulnar  veins,  which  are  only  the  con- 
tinuation of  the  cephalic  of  the  thumb  and  of  the  salvatella,  are 
the  two  principal.  The  first  is  sometimes  the  largest,  at  other 
times  the  second  ;  frequently  one  or  the  other  of  them  are  want- 
ing, from  their  roots  soon  passing  upon  the  palmar  surface.  They 
are  more  distinct  in  proportion  as  they  are  more  inferior,  and  we 
see  them  communicating  with  each  other  by  transverse  branches. 
We  seldom  draw  blood  from  them ;  not  because  the  operation 
would  be  dangerous,  for  they  are  surrounded  by  a  small  number 
of  nervous  filaments  only,  but  because  there  are  others  much 
more  easy  to  open  and  of  a  larger  calibre. 

The  deep-seated  veins  follow  exactly  the  course  of  the  arteries. 

vn.  The  Lymphatics. 

They  are  not  very  numerous.  Those  of  the  superficial  layer 
gradually  turn  over  the  sides  of  the  ulna  and  radius,  but  especially 

41 


OF    THE    THORACIC    EXTREMITIES. 

the  latter,  in  order  to  enter  the  anterior  region ;  those  of  the 
deep-seated  parts  ascend  with  the  bloodvessels,  and  follow  the 
same  course.  This  scarcity  in  the  lymphatic  system,  the  hairs 
which  cover  the  skin,  and  the  other  characters  peculiar  to  this 
membrane  in  the  region  under  consideration,  are  the  principal 
reasons  why  we  do  not  apply  to  it  medicaments,  which  we  wish 
to  have  absorbed,  in  the  form  of  frictions ;  on  the  other  hand, 
dry  frictions,  or  simply  revulsives,  will  produce  more  effect  upon 
it  than  upon  the  anterior  part  of  the  limb. 

vin.  The  Nerves. 

The  posterior  branch  of  the  radial  nerve  is  found  externally 
and  superiorly.  Its  twigs,  like  those  of  the  posterior  interosseous 
artery,  which  they  accompany  almost  every  where,  are  dispersed 
among  the  fibres  of  the  superficial  muscles;  a  few  filaments, 
however,  are  lost  in  the  deep  muscular  stratum.  The  median 
and  ulnar  send  off  some  delicate  but  numerous  filaments  near  the 
elbow,  which  are  distributed  to  the  internal  and  superior  part  of 
the  region.  Inferiorly,  we  see,  internally  and  externally,  the 
posterior  branches  of  the  radial  and  ulnar  nerves  immediately 
applied  against  the  bones ;  and  in  the  middle,  in  the  bottom  of 
the  space,  the  posterior  iuterosseous  filament  derived  from  the 
median.  According  to  the  disposition  of  these  last  branches,  we 
conceive  that,  in  fractures  near  the  wrist,  they  may  be  painfully 
stretched,  contused,  or  even  divided  ;  and,  from  their  volume,  we 
may  expect  severe  symptoms  to  follow  such  accidents.  We 
ought  likewise  to  note  the  posterior  branches  of  the  internal 
cutaneous  and  musculo-cutaneus  nerves,  which  ramify  in  the 
superficial  cellular  layer  around  the  veins,  but  which  afford  no 
interest  in  relation  to  operations. 

ix.  The  Skeleton. 

The  two  bones  of  the  fore-arm,  which  compose  it,  are  so  dis- 
posed that  the  radius  is  largest  inferiorly  and  the  ulna  superiorly; 
whence  it  follows  that,  united,  they  give  to  the  skeleton  of  the 
fore-arm  nearly  equal  transverse  dimensions  throughout  its  whole 
extent.  It  also  results  from  this  arrangement,  that  the  former  is 


OP  THE  THORACIC  EXTREMITIES.  323 

more  frequently  broken  superiorly  than  inferiorly,  whereas  the 
reverse  takes  place  with  respect  to  the  ulna;  and  that,  when  both 
bones  are  broken  simultaneously,  the  solution  of  continuity  sel- 
dom occurs  in  the  same  line.  They  are  convex,  and  slightly  curv- 
ed upon  the  faces  which  are  directed  towards  the  circumference 
of  the  limb,  and  are  separated,  on  the  side  of  the  median  line,  by 
the  interosseal  space ;  a  space  an  inch  in  breadth  in  some  persons, 
four  or  five  lines  in  others,  and  which  gradually  diminishes  in 
proportion  as  it  approximates  the  extremities  of  the  region.  As 
this  space  is  closed  only  by  a  fibrous  membrane,  and  as  the  bones 
become  so  much  attenuated  when  they  reach  it  that  they  present 
a  cutting  margin,  it  thence  follows  that  the  anterior  surfaces  of 
the  ulna,  radius  and  interosseous  ligament  represent  a  species  of 
fossa,  which  is  deeper  and  broader  in  proportion  to  the  degree  of 
separation  between  these  bones :  it  is  in  this  fossa  that  the  mus- 
cles are  lodged.  The  same  is  observed  at  the  the  posterior  part ; 
hence  the  antero-posterior  diameter  of  the  fore-arm  is  naturally 
shorter  than  the  transverse.  Therefore,  when  these  bones  are 
fractured,  we  place  graduated  compresses  and  splints  upon  the 
extremities  of  the  first  diameter  in  order  to  elongate  it,  and  pre- 
vent them  from  approximating.  Besides,  it  may  be  observed 
that  the  displacement  of  the  bones  is  not  difficult  to  overcome  in 
fractures  of  the  fore-arm.  Indeed,  in  order  that  the  fragments 
should  be  displaced  longitudinally,  it  is  necessary  that  both  the 
radius  and  ulna  should  be  broken  together ;  and  even  in  this  case 
the  thing  would  be  difficult,  unless  the  fracture  existed  quite  low 
down ;  for  the  attachments  of  the  muscles  being  continued  upon 
both  divided  extremities,  they  would  not  tend  to  make  them  ride 
past  each  other.  If  the  radius  only  is  broken,  the  two  fragments 
will,  it  is  true,  be  drawn  towards  the  ulna,  superiorly,  by  the 
pronator  teres,  inferiorly,  by  the  pronator  quadratus,  and  the 
interosseous  space  will  disappear ;  the  osseous  portion  into  which 
the  pronator  teres  is  inserted  will  also  pass  before  the  other ;  but 
it  is  sufficient  to  relax  the  muscles,  and  apply  graduated  compres- 
ses, in  order  to  restore  the  parts  to  their  natural  situation.  If  the 
ulna  alone  is  fractured,  the  displacement  can  only  take  place 
transversely,  and  that  in  the  inferior  fragment ;  for  the  articula- 
tion of  the  superior  fragment  does  not  admit  of  its  moving  later- 
ally. As,  in  this  case,  if  the  fracture  exists  very  low  down,  the 


324  OF    THE    THORACIC    EXTREMITIES. 

antero-posterior  compression  is  not  sufficiently  efficacious,  M. 
Dupuytren  has  recommended,  in  order  to  carry  the  inferior  por- 
tion of  the  fractured  bone  inwards,  to  maintain  the  hand  forcibly 
inclined  upon  its  radial  border. 

All  these  fractures  may  be  produced  by  indirect  causes ;  but 
they  are  likewise  very  frequent  from  the  action  of  direct  causes, 
especially  upon  the  radius,  which  is  very  superficial,  and  the  ex- 
tremities of  which  are  so  placed  upon  the  ulna,  that,  the  latter 
being  supported  upon  a  solid  body,  an  external  pressure  act- 
ing upon  the  convexity  of  the  other,  will  not  fail,  if  the  force  is 
sufficient,  to  break  it  by  the  effort  which  would  tend  to  straight- 
en its  curvature. 

As  the  radius  cannot  rotate  upon  the  ulna  but  at  the  expense 
of  the  interosseal  space,  it  is  easy  to  comprehend  why  fractures, 
which  are  consolidated  in  a  wrong  position,  will  impede,  or  pre- 
vent the  pronation  of  the  hand.  On  the  other  hand,  it  is  neces- 
sary to  note  that  in  forced  pronation,  this  space  entirely  disap- 
pears, the  radius  then  swings  upon  the  ulna,  and  represents  a 
lever  of  the  first  order,  the  power  of  which  is  at  its  inferior  por- 
tion :  whence  luxation  of  its  superior  extremity  backwards.  Su- 
pination,  on  the  contrary,  by  separating  the  bones,  tends  to  luxate 
the  head  of  the  radius  forwards :  hence  this  accident  is  very  com- 
mon in  young  children  whose  nurses  are  in  the  .habit  of  lifting 
them  by  the  hand,  in  order  to  assist  them  in  making  a  long  step. 

In  amputations,  these  bones  must  be  held  in  a  state  of  forced 
pronation,  in  order  to  avoid  jarring  the  articulations  of  the  radius 
during  the  action  of  the  saw.  It  is  for  the  same  reason,  and  in 
order  that  the  section  may  terminate  by  the  least  moveable  bone, 
that  we  recommend  the  surgeon  to  hold  it  inwards. 

These  operations  here  present  different  peculiarities,  according 
to  the  part  of  the  limb  upon  which  they  are  performed.  The  skin, 
as  we  have  seen,  is  every  where  very  moveable  ;  it  will  always 
be  easy  to  draw  it  up  as  far  as  is  required  without  dissecting  it, 
as  was  the  practice  of  J.  L.  Petit ;  but  as  the  volume  of  the  parts 
to  be  covered  is  less  inferiorly  than  superiorly,  it  will  be  necessa- 
ry to  preserve  more  of  it  in  the  latter  direction. 

If  the  operation  is  performed  near  the  wrist,  we  will  only  have 
the  radial  and  ulnar  arteries  to  tie ;  it  will  not  be  necessary  to 
pass  the  knife  into  the  interosseal  space  ;  but,  on  the  other  hand, 


OF   THE    THORACIC    EXTREMITIES,  325 

we  will  scarcely  meet  with  any  thing  more  than  the  tendinous 
portion  of  the  muscles,  the  synovial  tissue  and  the  species  of  web 
which  constitutes  it ;  the  soft  parts  will  have  but  a  slight  degree 
of  thickness,  and  the  skin  alone  will  remain  applied  upon  the  ex- 
tremity of  the  bones. 

In  the  middle  portion,  on  the  contrary,  the  radial,  ulnar,  anteri- 
or and  posterior  interosseous  arteries  will  each  require  a  ligature  ; 
it  will  be  necessary  to  cut  the  muscles  between  the  bones;  but  here 
the  muscular  mass  is  considerable  ;  there  are  no  longer  tendons 
nor  synovial  membrane  in  this  situation,  and  it  will  always  be  pos- 
sible to  preserve  as  much  of  the  soft  parts  as  will  favour  the  im- 
mediate union  of  the  wound.  Therefore,  notwithstanding  the  ad- 
vantage of  preserving  a  greater  length  of  limb,  M.  Larrey  and 
other  surgeons  always  advise  amputating  in  the  muscular  portion 
of  the  fore-arm.  Nevertheless,  with  due  deference  to  the  opinion 
of  M.  Larry,  whose  authority  is  doubtless  imposing  on  this  sub- 
ject, we  think,  with  many  others,  that  the  amputation  should  be 
made  as  low  down  as  the  disease  will  permit,  and  observation 
has  sufficiently  proved  that  such  cases  succeed  full  as  well,  and 
that  the  cicatrix  is  quite  as  firm  as  when  the  operation  is  per- 
formed higher  up ;  only  it  seems  to  us  that,  instead  of  keeping 
the  extremity  of  the  stump  more  elevated  than  the  elbow,  dur- 
ing the  subsequent  treatment,  with  the  view  of  preventing  a  de- 
termination of  blood  towards  the  part,  it  would  be  much  better  to 
keep  it  in  a  dependent  position  ;  for,  in  the  first  case,  it  is  evident 
that  the  pus,  if  it  forms,  and  the  inflammation  will  be  almost 
necessarily  propagated  towards  the  fold  of  the  arm,  through  the 
medium  of  the  retracted  tendons  and  their  envelopes,  by  the 
cellular  tissue,  the  veins  and  the  lymphatics ;  whilst,  in  the  latter^ 
all  the  inflammatory  phoenomena  will  be  confined  to  the  wound. 

Again,  the  fore-arm  is  that  portion  of  the  limbs  which  is  best 
adapted  for  the  flap  amputation,  according  to  the  method  of  Ver- 
male,  if  it  is  true  that  it  presents  greater  advantages  than  the 
circular  operation.  It  is  invariably  the  case,  in  operating  upon 
the  inferior  portion  of  the  fore-arm  by  the  latter  method,  that  the 
tedons  and  other  soft  parts  will  roll  under  the  instrument,  will  be 
pressed  by  it  between  the  bones,  and  consequently  be  divided 
with  difficulty ;  and  in  amputating  higher  up,  by  the  same  pro- 
^ess.  that  the  muscles  will  also  be  divided  in  an  unequal  manner, 


326  OF    THE    THORACIC    EXTREMITIES. 

especially  externally,  and  that  their  section  upon  the  anterior  and 
posterior  surfaces  of  the  bones  will  not  always  be  less  difficult. 
Consequently,  it  appears  to  us  that  the  two  methods  might  be 
combined  with  advantage,  as  M.  J.  Cloquet  has  proposed ;  or 
rather  that  the  operation  would  be  more  expeditious  and  safe  by 
commencing  with  a  circular  incision  through  the  skin,  which  is 
to  be  sufficiently  raised,  an  d  afterwards  dividing  the  muscles  by 
passing  cautiously  from  one  side  to  the  other,  between  them  and 
the  bones,  a  narrow  knife,  the  edge  of  which  would  finally  be 
directed  perpendicularly  to  their  fibres. 

Sect.  3.  Borders  of  the  Fore- Arm. 

1.  The  External,  or  radial  border,  is  formed  superiorly  by  the 
external  muscular  eminence  of  the  fold  of  the  arm,  and  is  conse- 
quently found  almost  entirely  in  the  anterior  region.     Below  this 
prominence,  the  radius  is  subcutaneous ;  more  inferiorly,  we  ob- 
serve the  eminence  produced  by  the  muscles  which  pass  to  the 
thumb.     In  order,  therefore,  to  distinguish  fractures  of  the  radius 
by  following  the  external  surface  of  this  bone,  we  must  feel  along 
the  external  groove  of  the  dorsal  aspect  of  the  fore-arm.     The 
parts  composing  this  border  have  already  been  described. 

2.  The  Internal,  or  Ulnar  Border,  presents  superiorly  the  side 
of  the  internal  muscular  eminence,  which  descends  lower  than  the 
external ;  inferiorly,  the  ulna  is  covered  by  the  skin  only ;  so  that 
the  superior  half  of  this  bone  is  actually  in  the  posterior  region, 
and  that,  in  order  to  ascertain  its  fracture,  it  is  necessary  to  trace 
it  behind,  in  the  direction  of  a  line  which  would  pass  from  the 
internal  part  of  the  olecranon  to  its  styloid  process :  in  the  same 
manner  that,  with  respect  to  the  radius,  we  would  follow  another, 
proceeding  from  the  posterior  part  of  the  condyle  of  the  humerus 
to  the  styliforme  apophysis  of  the  radius. 

From  what  has  just  been  said,  we  see  that,  properly  speaking, 
these  borders  do  not  exist  as  distinct  regions ;  that  their  superior 
half  enters  into  the  palmar  aspect,  and  that  their  inferior  half 
appertains  to  the  dorsal  region  :  therefore  we  will  not  dwell  any 
longer  upon  them. 


OP    THE    THORACIC    EXTREMITIES.  327 


ART.  V.  OF  THE  WRIST. 

This  part  consists  of  that  assemblage  of  organs  which  is  com- 
prised between  the  two  regions  of  the  fore-arm  and  a  circular 
line  which  would  pass  below  the  os  pisiforme  and  upon  the  root 
of  the  thumb ;  it  consequently  includes  all  the  articulations  of  the 
bones  of  the  carpus  with  each  other,  with  the  bones  of  the  fore- 
arm and  with  the  hand.  Its  length  is  about  two  inches.  It  will 
be  divided  into  two  regions,  by  the  two  lines  which  continue  the 
anterior  border  of  the  radius  and  the  head  of  the  ulna,  towards 
the  carpo-metacarpal  articulation  of  the  thumb  and  the  posterior 
extremity  of  the  fifth  metacarpal  bone. 

Sect.  1.  Anterior  Region. 

Its  transverse  extent  is  from  two  to  two  and  a  half  inches.  In 
examining  its  surface,  through  the  skin,  we  feel,  from  without  in- 
wards ; — 1st.  a  prominence  formed  by  the  conjoined  tendons  of  the 
abductor  longus  and  extensor  brevis  pollicis,  a  prominence  which 
seems  to  be  continuous  above  with  the  anterior  crista  and  styloid 
process  of  the  radius ; — 2nd,  a.  fossette  which  terminates  the  radial 
groove  of  the  fore-arm,  and  by  which  we  may  penetrate  into  the 
joint  — 3rd,  below  and  within  this  fossette,  a  second  eminence 
which  corresponds  to  the  crests  of  the  scaphoides  and  trapezium, 
and  which  may  be  readily  distinguished  when  the  hand  is  thrown 
back.  If  the  thumb  and  little  finger  are  in  contact,  and  the  other 
fingers  extended  whilst  the  wrist  is  flexed  upon  the  fore-arm,  an 
extremely  prominent  cord  will  be  seen  passing  upon  the  preced- 
ing relief:  this  cord  is  formed  by  the  tendon  of  the  palmaris 
longus.  In  the  state  of  rest,  this  tendon  and  the  bones  just 
mentioned  gradually  subside  into  the  middle  prominence  of  the 
wrist,  which  is  itself  formed  by  the  tendons  of  all  the  flexors  and 
of  the  anterior  radial ; — 4th,  a  second  fossette,  which  terminates 
the  ulnar  groove  of  the  fore-arm,  and  which  corresponds  to  the 
artery  of  the  same  name ; — 5th,  the  eminence  represented  by  the 
os  pisiforme  and  the  tendon  of  the  flexor  carpi  ulnaris,  and  behind 
which  we  meet  with  another  fossette  surmounted  bv  the  head 


328  OF    THE    THORACIC    EXTREMITIES. 

of  the  ulna ; — finally,  in  the  middle  and  most  inferior  part,  a  super- 
ficial excavation  which  leads  into  the  palm  of  the  hand. 

CONSTITUENT    PARTS. 

i.  The  Skin. 

The  skin  does  not  present  exactly  the  same  characters  upon 
the  fore  part  of  the  wrist  that  it  does  on  the  palmar  aspect  of  the 
fore-arm  ;  it  is  destitute  of  hairs,  but  wrinkles  are  observed  in  it 
in  greater  or  less  numbers,  according  to  the  age,  sex,  and  embon- 
point. Among  these  wrinkles,  three  especially  are  conspicuous, 
which  may  serve  as  guides  in  operations.  The  first  is  found 
upon  the  superior  limits  of  the  region,  half  an  inch  above  the 
styloid  process  of  the  radius :  it  is  occasionally  wanting.  The 
two  extremities  of  the  second  terminate  at  the  apex  of  the  styloid 
process  of  the  radius  and  of  the  ulna ;  it  corresponds  to  the  radio- 
carpal  articulation.  Finally,  the  third,  still  more  distinct  than 
the  preceding,  is  slightly  convex  downwards ;  it  separates  the 
thenar  and  hypothenar  eminences,  as  well  as  the  palm  of  the 
hand  from  the  wrist  properly  so  called.  By  cutting  upon  it,  we 
would  fall  directly  upon  the  articulation  of  the  two  carpal  rows. 
Below  this  last  the  skin  is  smooth,  although  thick  and  more  com- 
pact :  it  then  makes  a  part  of  the  palmar  integuments  of  the 
hand. 

ii.  The  Subcutaneous  Layer. 

This  layer  is  formed  of  very  dense  and  slightly  extensible  cel- 
lular lamellae  and  filaments,  and  never  acquires  great  thickness, 
although  it  contains  a  considerable  quantity  of  adipose  vesicles, 
which  are  met  with  in  the  upper,  seldom  in  the  lower,  and  still 
more  rarely  in  the  middle  portion.  As  this  layer  is  rather  fibrous 
than  cellular,  and  unites  the  aponeurosis  and  annular  ligament 
intimately  to  the  skin,  serous,  sanguineous  or  purulent  secre- 
tions can  never  separate  these  two  membranes ;  so  that  in  drop- 
sical persons,  as  well  as  in  those  who  are  loaded  with  fat,  we 
observe  a  kind  of  strangulation  at  the  wrist,  The  same  thing  is 
pretty  generally  noticed  in  women  and  children.  In  this  layer 


OF    THE    THORACIC    EXTREMITIES. 

the  superficial  veins  and  nerves  take  their  course.  It  is  import- 
ant to  distinguish  diseases  developed  in  this  tissue,  from  those 
which  are  more  deeply  seated. 

in.  The  Apvnmrosis. 

Above  the  radio-carpal  articulation,  it  has  the  same  arrange- 
ment as  was  detailed  in  the  anterior  anti-brachial  region ;  but 
below  this  it  is  complicated  in  a  very  remarkable  manner.  If 
we  commence  with  it  at  the  head  of  the  ulna  and  the  os  pisi- 
forme,  we  will  perceive  that  it  splits  in  order  to  envelope  the 
tendon  of  the  flexor  carpi  ulnaris,  and  that  it  afterwards  gives  a 
sheath  to  the  ulnar  artery ;  its  laminae  are  then  re-applied  upon  the 
fore  part  of  the  flexor  tendons,  in  order  to  separate  anew,  envel- 
oping the  tendon  of  the  palmaris  longus  in  the  first  place,  then 
that  of  the  flexor  carpi  radialis,  and  afterwards  forming  a  sheath 
for  the  radial  artery ;  it  then  passes  to  fix  itself  to  the  anterior 
border  of  the  styloid  process  of  the  radius  and  becomes  blended 
with  the  fibrous  canal  in  which  the  tendon  of  the  abductor  longus 
pollicis  runs.  Inferiorly,  its  fibres  are  approximated,  condensed, 
and  thus  seem  to  give  origin  to  the  anterior  annular  ligament  of 
the  carpus,  before  which  the  tendon  of  the  palmaris  longus  ex- 
pands, and  is  transformed,  as  it  were,  into  an  aponeurosis ;  which 
makes  the  ligament  appear  as  if  formed  of  two  layers :  one  with 
diverging  fibres,  appertaining  to  the  tendon;  the  other,  with 
transverse  fibres,  the  continuation  of  the  aponeurosis.  This  lig- 
ament is  attached,  on  the  one  hand,  to  the  os  pisiforme  and  the 
process  of  the  os  unciforme ;  on  the  other,  to  the  crest  of  the 
scaphoides  and  trapezium.  In  terminating,  this  last  extremity 
splits  in  order  to  form  a  sheath  for  the  tendon  of  the  flexor  carpi 
radialis.  Its  inferior  border  is  continuous  with  the  palmar  apo- 
neurosis ;  in  the  middle  and  upon  the  sides,  the  fleshy  fibres  of  the 
thenar  and  hypothenar  eminences  derive  their  attachments  from 
it.  We  have  already  said  that,  superiorly,  it  was  continuous 
with  the  aponeurosis.  According  to  this  arrangement,  the  ante- 
rior carpal  ligament  forms  the  anterior  half  of  a  complete  ellip- 
tical ring,  the  transverse  diameter  of  which  is  twenty  one  lines, 
and  its  antero-posterior,  one  inch  only.  This  ring,  or  canal, 
encloses  all  the  tendons  of  the  two  common  flexors  and  that  of 

49 


330  OF   THE    TIIO11ACIC    EXTREMITIES, 

the  thumb ;  those  of  the  palrnaris  longus  and  of  the  flexores  carpi 
radialis  et  ulnaris  are  without  it ;  the  median  nerve  passes  through 
it ;  but  the  radial  and  ulnar  arteries,  as  well  as  their  concomi- 
tant nerves,  are  external  to  it.  As  it  is  very  strong  and  unyield- 
ing, it  invincibly  resists  the  protrusion  of  tumours  which  are 
deeply  situated  and  forces  them  towards  the  hand  or  fore-arm. 
We  will  again  recur  to  this  subject. 

iv.  The  Muscles. 

Strictly  speaking,  this  region  does  not  contain  any ;  we  only 
find  in  it  a  very  small  portion  of  the  superior  extremity  of  the 
muscles  forming  the  ball  of  the  thumb  and  little  finger,  and  the 
most  inferior  fibres  of  the  pronator  quadratus ;  but  if  there  are 
no  fleshy  bundles,  we  find  in  it  a  great  number  of  tendons. 
Quite  externally,  we  see  the  termination  of  the  supinator  longus 
upon  the  base  of  the  styloid  process,  and  the  tendons  which  go 
to  the  thumb.  These  last  are  included  in  a  very  strong  fibrous 
theca,  which  is  lined  by  a  synovial  membrane,  and  they  are  those 
tendons  which,  as  we  have  stated,  produce  the  first  prominence 
observed  externally.  They  are  so  distant  from  the  articulation 
that  the  point  of  an  instrument,  entered  at  the  fossette  which 
separates  them  from  the  second  eminence,  might  pass  between 
them,  from  before  backwards,  without  opening  the  joint.  The 
tendon  of  the  palmaris  longus  is  at  first  upon  the  median  line  ; 
then  it  descends  obliquely  outwards  and  expands  upon  the  annu- 
lar ligament,  with  which  it  is  blended.  As  it  is  only  enveloped 
by  the  superficial  laminae  of  the  aponeurosis,  it  is  strongly  delin- 
eated through  the  skin  when  its  muscle  is  brought  into  action,  the 
thumb  being  at  the  same  time  thrown  into  forced  opposition. 
External  to  it  and  a  little  deeper,  we  distinguish  the  tendon  of 
the  flexor  carpi  radialis,  the  fibrous  sheath  of  which  is  stronger 
and  more  complete  than  that  of  the  preceding.  As  it  passes  to 
the  second  metacarpal  bone,  this  tendon  dips  into  a  very  strong 
canal  which  is  formed  for  it  by  the  os  scaphoides  and  trapezium, 
on  the  one  hand,  and  the  external  extremity  of  the  annular  liga- 
ment on  the  other.  The  flexor  carpi  ulnaris,  having  likewise  a 
distinct  fibrous  canal,  also  raises  the  skin  in  the  flexion  and  ad- 
duction of  the  wrist.  During  the  forced  adduction  of  the  little 


OP  THE  THORACIC  EXTREMITIES.  331 

finger,  it  is  sufficiently  separated  from  the  bones  of  the  carpus  to 
admit  of  the  passage  of  a  pointed  instrument  between  it  and  the 
articulation,  without  penetrating  into  the  latter.  If  the  instru- 
ment was  directed  obliquely  from  before  backwards,  and  from 
without  inwards,  or  even  in  the  opposite  direction,  it  is  probable 
that  a  similar  wound  would  rarely  fail  to  comprise  the  artery, 
and  even  the  anterior  branch  of  the  nerve.  These  different  ten- 
dons, having  each  a  distinct  sheath,  are  by  this  means  completely 
isolated  from  the  surrounding  parts,  so  that  they  may  easily  act 
independently  of  one  another. 

It  is  not  so  with  those  included  by  the  carpal  ring ;  the  flexor 
of  the  thumb  alone  seems  separated  from  the  others,  and  draws 
with  it  a  portion  of  the  fibro-cellular  bursa  which  envelopes  them 
all.  They  there  form  a  sort  of  bundle,  in  which  the  median 
nerve  is  also  found.  The  membrane  which  first  connects  them 
in  a  mass,  then  each  in  particular,  lines  the  whole  interior  of  the 
canal  which  contains  them.  Although  this  membrane  is  thin  and 
translucent,  it  nevertheless  possesses  much  firmness ;  its  texture 
is  evidently  fibrous,  and  it  possesses  the  greater  part  of  the  char- 
acters which  appertain  to  synovial  membranes.  In  the  natural 
state,  however,  we  seldom  find  in  it  much  fluid ;  it  is  only  lubri- 
cated, very  slippery,  and  polished.  Below  the  annular  ligament 
it  seems  to  terminate  in  a  cul-de-sac  ;  so  that  it  will  oppose  the 
infiltration  of  pus,  serum,  etc.,  in  deep-seated  affections  of  the 
wrist.  This  membrane  is  of  considerable  extent,  and  like  all 
others  of  the  same  nature,  it  readily  inflames  when  divided  by  an 
instrument,  or  even  from  simple  contact  with  the  external  air. 
This  inflammation,  which  in  itself  is  of  a  very  dangerous  nature, 
becomes  still  more  so  from  the  resistance  which  the  aponeurosis 
opposes  to  the  inflammatory  swelling  of  the  parts,  and  especially 
from  the  species  of  strangulation  which  the  anterior  ligament  of 
the  carpus  exercises  upon  it.  It  is  this  inflammation  which  ren- 
ders wounds,  contusions,  and  all  deep-seated  diseases  of  the 
wrist  so  dangerous,  and  which  we  must  apprehend  when  we  per- 
form any  important  operation  upon  this  part.  It  is  in  this  bursa 
that  we  have  most  frequently  seen  those  cartilaginous  granulations 
developed  of  which  we  treated  when  on  the  elbow ;  granulations 
which  do  not  appear  to  differ  much,  except  in  volume,  from  those 
aecidental  cartilages  which  are  sometimes  met  with  in  the  large 


33*2  OF  THE    THOKAC1C    EXTREMITIES. 

articulations ;  granulations,  finally,  which  have  been  regarded  as 
hydatids,  but  the  nature  of  which  we  are  as  yet  almost  ignorant 
of.  Be  this  as  it  may,  the  tumour  which  contains  them  here  al- 
most uniformly  has  the  peculiar  character  of  being  double,  or  of 
the  form  of  a  wallet ;  that  is  to  say,  it  projects  both  in  the  palm 
of  the  hand  and  fore  part  of  the  wrist  at  the  same  time,  which  is 
undoubtedly  owing  to  the  disposition  of  the  anterior  fibrous  arch 
of  the  carpus.  This  tumour,  which  does  not  seem  to  be  suscep- 
tible of  resolution,  produces  but  little  inconvenience,  unless  it 
acquires  a  large  volume ;  but  if  the  patient  wishes  to  get  rid  of 
it,  and  if  the  surgeon  decides  on  simply  opening  it,  or  passing  a 
seton  through  it,  the  operation  may  be  followed  by  the  most 
serious  con- equences,  even  death ;  which  has  occurred  several 
times  at  Hotel  Dieu.  In  1822,  we  saw  Prof.  Richerand,  at  the 
Hospital  St.  Louis,  open  a  similar  tumour  in  a  girl  nineteen  years 
of  age,  of  a  strong  and  good  constitution.  The  operation  was 
performed  with  every  necessary  precaution  ;  notwithstanding, 
intolerable  pains  ensued,  and  violent  reaction  manifested  itself; 
it  was  necessary  to  make  numerous  incisions,  which  did  not  pre- 
vent abscesses  from  forming,  and  this  girl  was  not  out  of  danger 
until  after  six  weeks  of  suffering,  combatted  by  the  most  ener- 
getic measures. 

v.  The  Arteries. 

In  the  first  place  we  find  the  Radial,  lying  upon  the  fore  part  of 
the  radius  and  pronator  quadratus  ;  when  it  reaches  the  fore  part 
of  the  styloid  process,  it  turns  backwards  and  passes  through  the 
space  which  separates  the  tendons  of  the  short  and  long  abduc- 
tors of  the  thumb  from  the  bones,  in  order  to  enter  the  posterior 
region ;  so  that  it  would  be  possible  to  discover  it  in  the  radial 
fossette  of  the  wrist,  and  that,  if  the  wound,  indicated  when  speak- 
ing of  this  tendinous  prominence,  occurred,  it  would  almost  neces- 
sarily involve  this  vessel.  Previous  to  changing  its  direction,  the 
radial  artery  sends  off  a  small  branch  to  the  thenar  eminence  ; 
then  a  second,  which  runs  towards  the  palmar  gutter  by  passing 
between  the  tendon  of  the  flexor  carpi  radialis  and  the  anterior 
annular  ligament.  This  vessel  is  sometimes  so  large  that  its  di- 
vision might  be  dangerous  ;  and,  in  such  a  case,  it  is  so  superficial 


OF    THT3    THORACIC    EXTREMITIES.  333 

that  it  may  be  exposed  and  secured.  In  terminating,  it  assists  in 
the  formation  of  the  superficial  palmar  arch. 

Next  the  Ulnar,  which  is  still  covered  by  the  tendon  of  the 
flexor  carpi  ulnaris  muscle,  and  by  two  aponeurotic  laminae,  as  in 
the  palmar  aspect  of  the  fore-arm  ;  therefore,  we  may  also  expose 
and  apply  a  ligature  around  it  by  following  the  directions  then 
given.  In  some  persons  it  is  so  superficial  that  its  pulsations 
may  be  easily  felt  in  the  ulnar  groove  of  this  region.  In  de- 
scending, this  artery  inclines  slightly  outwards,  in  order  to  pass 
over  the  fore  part  of  the  annular  ligament  and  the  radial  side  of 
the  os  pisiforme.  In  the  upper  part  of  the  region,  that  is  to  say, 
about  an  inch  above  the  head  of  the  ulna,  the  ulnar  artery  sends 
off  a  branch  which  varies  in  its  dimensions,  and  which  passes 
directly  upon  the  dorsum  of  the  wrist,  crossing  the  nerve,  which 
is  always  situated  behind  and  upon  the  inner  side  of  the  arterial 
trunk.  When  the  volume  of  this  branch  is  very  considerable,  it 
may  be  readily  felt  upon  the  internal  border  of  the  ulna-;  in 
which  case  also  a  cutting  instrument,  carried  upon  this  side, 
would  promptly  reach  it,  and  if  we  did  not  reflect  upon  it,  we 
might  be  persuaded  that  the  ulnar  itself  was  wounded. 

There  are  no  other  remarkable  branches  in  this  region. 

vi.  The  Veins. 

The  superficial  veins  form  a  more  or  less  complicated  net- 
work. They  usually  represent  an  arch,  the  convexity  of  which, 
turned  towards  the  hand,  receives  many  branches  from  this  por- 
tion of  the  limb,  and  the  extremities  of  which  constitute  the  roots 
of  the  median  and  ulnar  veins.  In  general,  the  external  branches 
are  larger  than  the  internal,  and  they  might  possibly  serve  for 
venesection  ;  but  we  seldom  open  them,  because  there  are  always 
others  more  voluminous.  The  deep-seated  are  applied  upon  the 
anterior  aspect,  or  upon  that  side  of  the  arteries  which  is  towards 
the  central  line  of  the  limb.  They  are  of  small  size  and  merit 
but  little  attention. 

vii.  The  Lymphatics. 
Disposed  as  in  the  fore-arm,  they  present  nothing  particular. 


334  OF   THE    THORACIC    EXTREMITIES 


viii.   The  Nerves. 

On  the  inner  side,  we  see  the  continuation  of  the  anterior 
branch  of  the  ulnar  nerve,  which  runs  directly  along  the  external 
side  of  the  artery  and  a  little  posterior  to  it ;  externally,  some 
twigs  of  the  radial ;  in  the  middle,  the  median,  the  volume  of 
which  usually  equals  that  of  the  tendons  with  which  it  is  min- 
gled. Before  the  median  enters  the  ring  of  the  carpus  it  gene- 
rally gives  off  its  cutaneous  palmar  branch,  \vhich  soon  becomes 
superficial  and  ramifies  in  the  subcutaneous  layer,  becoming 
blended  with  some  of  the  extreme  filaments  of  the  internal  cu- 
taneous and  musculo-cutaneus,  which  extend  thus  far.  From 
the  small  number  of  sensible  cords  which  are  met  with  in  this 
region,  we  may  be  permitted  to  advance  the  opinion,  that,  if  dis- 
eases are  more  dangerous  here  than  in  many  other  parts  of 
the  body,  we  must  not  seek  for  the  cause  of  it  in  Jhe  nervous 
system. 

ix.  T/te  Skeleton. 

The  skeleton  comprehends  the  anterior  faces  of  the  bones  of 
the  carpus,  of  the  head  of  the  metacarpal  bones,  and  of  the  ex- 
tremity of  those  of  the  fore-arm.  At  first  sight,  the  metacarpal 
bones  of  the  thumb  and  little  finger  only  would  seern  suscepti- 
ble of  being  luxated  forwards ;  but,  on  the  one  hand,  if  they 
possess  more  extensive  mobility  than  the  others,  and  if  their  lig- 
aments are  weaker ;  on  the  other,  the  root  of  the  muscles  which 
are  applied  upon  their  anterior  surfaces,  maintains  them  and  op-* 
poses  their  displacement.  The  bones  of  the  carpus  are  covered 
by  a  fibrous  membrane  so  strong  and  compact,  that  we  have  no 
example  of  their  luxation  upon  the  palmar  aspect.  In  fact,  in 
this  region  there  is  only  the  first  row  of  the  carpus  which  can  be 
luxated  upon  the  radius,  and  the  ulna  which  is  susceptible  of  be- 
ing displaced  forwards.  The  first  of  these  luxations,  without 
being  very  rare,  is,  however,  difficult  to  accomplish  ;  because,  on 
the  one  hand,  the  radio-carpal  ligament  is  very  strong,  and,  on  the 
other,  because  the  powers  which  tend  to  produce  it  press  the 
hand  firmly  backwards ;  whereby  all  the  flexor  tendons  are  ap- 


OF   TUB    THORACIC    EXTREMITIES. 

\>lied  very  firmly  against  the  bones,  and  thus  repel  them  with 
energy.  The  ulna  is  maintained  in  a  less  solid  manner  upon  the' 
carpus ;  but  its  relations  with  the  radius  are  so  fixed  that  its  lux- 
ation forwards  must  be  rare  and  difficult ;  we  have,  nevertheless, 
met  with  it  several  times,  and  we  conceive  that  it  may  take  place 
in  a  movement  of  forced  supination,  when  the  radius,  in  rotating 
backwards,  tends  to  tilt  in  a  direction  opposite  to  that  which  was 
mentioned  when  considering  its  superior  luxations.  In  the  move- 
ment of  forced  supination,  in  fact,  if  the  humeral  extremity  of 
the  radius  cannot  slip  forwards,  and  if  the  force  is  pretty  consid- 
erable, the  head  of  the  ulna  will  escape  from  the  cavity  which 
contains  it  below,  and  the  hand  will  remain  in  supination. 

In  examining  all  these  bones  covered  by  their  ligaments,  we 
see  superiorly,  and  from  within  outwards;  1st,  the  groove,  in 
which  is  the  tendon  of  the  flexor  carpi  ulnaris,  and  which  sepa- 
rates the  styloid  process  from  the  head  of  the  ulna ;  2d,  an  emi- 
nence formed  by  this  head  itself,  and  which  is  more  or  less  prom- 
inent according  to  the  position  of  the  hand ;  3d,  another  small 
groove  which  corresponds  to  the  radio-cubital  articulation ;  4th, 
a  second  prominence  represented  by  the  inferior  extremity  of  the 
radius,  and  which  terminates  externally  by  a  species  of  crest 
forming  the  anterior  border  of  the  styloid  process ;  5th,  below 
this,  we  find  a  large  transverse  semi-circular  groove,  the  convex- 
ity of  which  is  directed  upwards ;  this  groove  leads  directly  into 
the  articulation  of  the  fore-arm  with  the  carpus ;  its  two  extrem- 
ities separate  the  apex  of  the  radial  and  ulnar  apophyses  from 
the  os  pisiforme  and  from  the  crest  of  the  os  scaphoides ;  6th, 
still  lower  and  upon  the  radial  side,  the  eminence  formed  by  the 
trapezium  and  os  naviculare,  with  the  dispositions  of  which  we 
should  be  well  acquainted  in  amputating  at  the  wrist,  in  order  to 
avoid  striking  against  it  and  making  the  knife  glide  upon  the  fore 
part  of  it ;  7th,  internally,  and  upon  the  same  line,  the  promi- 
nence of  the  os  pisiforme  and  unciforme ;  this  deserves  still 
more  attention  than  the  preceding,  when  we  perform  the  flap  ope- 
ration at  the  wrist ;  on  the  one  hand,  because  it  is  more  evident, 
and  on  the  other,  because  it  would  be  more  easy  to  disarticulate 
the  os  pisiforme,  and  leave  it  in  the  flap ;  8th,  in  the  middle,  a 
very  deep  transverse  concavity,  which  forms  the  posterior  half 


336  OF    THE    THORACIC    EXTREMITIES. 

of  the  carpal  ring,  and  which  has  for  its  base  a  portion  of  the 
anterior  surface  of  the  trapezium,  scaphoides,  cunei forme,  and 
unciforme,  the  whole  of  the  trapezoides,  lunare,  and  magnum. 

From  what  has  preceded  we  find  that  the  order  of  supt-rposi- 
tion  of  the  parts  here  is  the  following:  1st,  the  skin;  *Jd,  the 
cellular  layer,  dense  and  compact,  enclosing  the  superficial 
veins  and  nerves ;  3d,  the  aponeurosis,  which  contains  in  its  lam- 
inae the  tendons  of  the  flexor  carpi  ulnaris,  palmaris  longus,  and 
flexor  carpi  radialis ;  and  still  deeper,  the  radial  and  ulnar  arte- 
ries and  nerves ;  4th,  the  anterior  annular  ligament,  uniting  the 
aponeuroses  of  the  hand  and  fore-arm  ;  5th,  the  flexor  tendons  of 
the  fingers  and  the  median  nerve  enveloped  by  their  synovial 
bursa ;  6th,  and  lastly,  the  ligaments  and  bones. 

Sect.  2.  The  Dorsal  or  Posterior  Region  of  the   Wrist. 

Upon  its  surface  we  observe,  from  without  inwards:  1st.  a 
fossette,  about  an  inch  in  breadth,  limited  above  and  below  by  the 
extremity  of  the  radius  and  the  root  of  the  thumb ;  anteriorly,  by 
the  first  eminence  of  the  anterior  region,  and,  externally,  by  the 
species  of  cord  which  is  represented  by  the  extensor  longus  pol- 
licis ;  the  radial  artery  crosses  the  bottom  of  this  fossette,  the 
depth  of  which  is  much  more  apparent  when  the  thumb  is  in  abduc- 
tion and  extension  ;  2d.  the  thumb  being  in  the  same  position,  and 
the  indicator  extended  whilst  the  other  fingers  are  flexed,  another 
excavation  of  less  depth,  but  broader,  limited  externally  by  the 
tendon  of  the  extensor  longus  pollicis,  and  internally  by  that  of 
the  extensor  indicis,  which  excavation  is  divided  by  the  tendon 
of  the  extensor  radialis  brevior  into  two  triangular  portions ;  one, 
external,  containing  the  head  of  the  second  metacarpal  bone  and 
the  termination  of  the  radial  artery,  a  little  more  externally ;  the 
other,  on  the  contrary,  internal,  having  its  base  towards  the 
radius,  and  which  will  guide  us  directly  into  the  joint ;  3d.  another 
fossette,  which  corresponds  to  the  interval  of  the  extensor  ten- 
dons of  the  ring  and  little  fingers  ;  4th.  more  internally,  a  small 
excavation,  which  is  also  found  between  this  last  tendon  and 
that  of  the  extensor  carpi  ulnaris;  in  this  is  situated  the  head  of 
the  ulna,  which  sometimes  projects  considerably ;  5th.  the  depre?- 


OP    THE    THORACIC    EXTREMITIES.  337 

sion  which  separates  the  tendons  of  the  flexor  and  extensor  carpi 
ulnaris,  as  well  as  the  two  regions  of  the  wrist  internally.  These 
different  excavations,  circumscribed  by  as  many  eminences,  per- 
mit, on  the  one  hand,  pointed  instruments  to  enter  into  the  ar- 
ticulations, without  dividing  the  tendons ;  and  on  the  other,  to 
synovial  tumours,  and  nodi,  to  project  under  the  skin. 

CONSTITUENT    PARTS. 

i.  The  Skin. 

This  is  supple,  extensible  and  covered  with  numerous  hairs  in 
man  ;  it  is  less  delicate  than^upon  the  palmar  surface,  and  contains 
some  indistinct  sebaceous  follicles.  Although  uneven  and  rough, 
it  does  not  present  any  complete  wrinkles ;  it  only  seems  as  if 
the  epidermis  was  too  large  for  this  region,  and  therefore  thrown 
into  folds  in  all  directions.  The  skin  upon  the  dorsal  surface  of 
the  wrist  is  always  of  a  darker  hue  than  that  of  the  anterior  region. 

k     ii.  The  Subcutaneous  Layer. 

It  preserves  all  the  characters  which  it  possessed  in  the  fore- 
arm, and  therefore  differs  much  from  the  subcutaneous  layer  of 
the  anterior  region :  hence  tumours  may  be  developed  under  it 
as  in  the  rest  of  the  limb,  and  increase  to  pretty  large  dimensions. 
This  layer  equally  contains  the  superficial  veins  and  some  nerves ; 
but  is  destitute  of,  or  contains  but  very  few  fatty  cells,  at  least  in 
the  vicinity  of  the  posterior  annular  ligament,  to  which  its  adhesion 
is  stronger  than  elsewhere  ;  from  which  circumstance  this  portion, 
in  children,  females  and  fat  subjects,  or  where  the  arm  is  cedema- 
tous,  appears  as  if  strangulated. 

in.  The  Aponeurosis. 

From  the  styloid  process  of  the  radius  to  that  of  the  ulna,  the 
aponeurosis  forms  a  very  strong  broad  arcade,  destined  to  bind 
down  the  tendons,  to  which  it  furnishes  separate  sheaths :  this  is 
the  ligamentum  carpi  annulare  postering.  The  different  canals 

43 


338  OF   THE    THORACIC    EXTREMITIES. 

to  which  this  ligament  gives  rise  from  without  inwards  are :  1st. 
behind  and  external  to  the  styloid  process  of  the  radius,  a  very 
strong  theca  directed  obliquely  forwards  and  downwards,  for  the 
tendons  of  the  extensor  brevis  (extensor  secundi  internodii)  and 
abductor  longus  pollicis  (extensor  primi  internodii) :  this  sheath 
constitutes  a  complete  canal,  and  when  it  is  divided  into  two  by  a 
septum,  the  extensor  (secundi)  tendon  lies  posteriorly.  2d, 
another  theca,  which  descends  perpendicularly,  and  encloses  the 
tendons  of  the  extensores  radialis  longior  et  brevior ;  3d,  the 
fibrous  canal  which  envelopes  the  tendon  of  the  extensor  longus 
pollicis  (extensor  tertii  internodii)'.  this  canal  is  oblique  in  the  same 
direction,  as  the  first,  and  is  only  complete  below  the  radius  ;  more 
superiorly  it  is  separated  from  the  sheath  common  to  the  entensors 
of  the  fingers  only  by  a  slightly  extensible  fibro-cellular  lamina  ; 
4th,  the  canal,  or  rather  the  proper  posterior  carpal  ring,  through 
which  the  tendons  of  the  extensor  communis  and  indicator  pass ; 
5th,  a  separate  sheath  for  the  extensor  minimi  digiti ;  6th,  be- 
tween the  styloid  process  and  the  head  of  the  ulna,  another  theca 
for  the  tendon  of  the  extensor  carpi  ulnaris.  On  the  side  of  the 
anti-brachial  region,  this  ligament  gradually  becomes  thinner,  its 
fibres  separate,  and  are  finally  blended  with  those  of  the  aponeu- 
rosis.  Its  inferior  margin  is  converted  into  a  fibro-cellular  lamina, 
which  is  at  first  very  thin,  but  afterwards  becomes  thicker  as  it 
passes  to  the  hand. 

iv.  The  Muscles,  or  rather  Tendons. 

The  tendons  of  all  the  extensor  muscles  of  the  fingers  and  hand 
traverse  the  posterior  region  of  the  wrist.  They  are  twelve  in 
number,  and  were  made  known  when  describing  the  sheaths 
which  they  derive  from  the  aponeurosis.  Those  which  form  the 
external  limit  of  the  fossette  of  the  first  metacarpal  bone,  were 
seen  when  on  the  palmar  surface.  The  extensores  radialis  lon- 
gior et  brevior  diverge  as  they  descend  ;  they  are  usually  sepa- 
rated in  their  sheath  by  a  fibrous  septum,  and  crossed  by  the  ex- 
tensor pollicis  longus,  which  is  itself  interposed  between  the  fos- 
sette of  the  first  metacarpal  bone  and  that  of  the  second.  The 
four  tendons  of  the  extensor  communis.  and  that  of  the  indicator 


OP   THE    THORACIC    EXTREMITIES.  339 

are  disposed  in  their  ring,  like  those  of  the  flexors  anteriorly  ;  that 
is  to  say,  that  a  sort  of  very  strong,  fibrous,  synovial  membrane 
envelopes  them,  and  permits  them  to  slide  easily,  either  separately 
or  conjointly.     This  membrane  does  not,  however,  form  a  com- 
plete bursa,  and  seems  less  complicated  than  that  of  the  anterior 
region.      It  lines   all  the  thccce,  and  covers  all  the  tendons  which 
run  through  them.     The  same  surgical  remarks  will  apply  to  it 
as  to  all  other  organs  of  the  same  nature  :  nevertheless,  as  the 
circumjacent  tissues  are  less  dense  than  in  the  anterior  region,  its 
inflammations  generally  produce  less  acute  pain  and  less  formi- 
dable symptoms.     We  have  not  met  within  it  those  cartilaginous 
corpuscules  which  were  mentioned  as  sometimes  existing  in  the 
palmar  portion  ;  but  those  synovial  tumours  called  nodi,  or  gan- 
glions, are  frequently  developed  in  it.      It  is  true  that  these  tu- 
mours may  also  depend  upon  a  species  of  hernia  of  the  articular 
synovial  capsule  ;  but  most  frequently  it  is  the  membrane  under 
consideration  in  which  they  are  situated.     In  this  case,  as  in  the 
other,  it  is  always  dangerous  to  open  these  species  of  cysts,  in 
consequence  of  the  inflammation  which  frequently  ensues,  and 
which  rapidly  extends  from  the  incised  sac  into  all  the  tendinous 
sheaths,  to  the  fore-arm,  hand,  etc.     There  is  at  present  in  the 
hospital  of  la  F  iculte,  an  adult  female,  who  has  had  one  of  tiiese 
tumours  over  the   track  of  the  extensor  longus  pollicis  for  six 
years,  and  which  she  was  desirous  of  getting  rid  of.      A  young 
surgeon  wished  to  try  the  radical  cure  for  hydrocele  ;  he  punc- 
tured it,  injected  a  small  quantity  of  cold  water  into  it,  and  re- 
commended rest ;  an  intense  fever  supervened,  abscesses  formed 
in  the  thecae,  fore-arm,  and  upon  the  back  of  the  hand,  etc. ;  it 
became  necessary  to  make  several  incisions,  and  this  woman  is 
not  yet  out  of  danger,  although  more  than  a  month  has  elapsed 
since  the  operation. 

v.  The  Arteries. 

The  Radial  is  the  largest,  and  is  the  only  one  which  deserves 
some  attention.  As  it  is  passing  behind  the  root  of  the  thumb, 
in  the  fossette  of  this  finger,  in  order  to  reach  the  first  inter- 
osseal  space  of  the  metacarpus,  it  is  deeply  seated  and  is  crossed 
by  the  tendons  of  the  extensor  pollicis  brevis  and  abductor  Ion- 


•>40  OF    THE    THORACIC    EXTREMITIES. 

gus  pollicis,  on  the  one  part,  and  the  extensor  pollicis  longus,  OM 
the  other.  In  order  to  discover  it  in  the  excavation  which  sepa- 
rates these  tendons,  we  would  have  to  divide  only  the  skin  and  a 
pretty  thick  layer  of  cellular  tissue. 

The  dorsal  artery  of  the  carpus  and  the  posterior  branch  de- 
rived from  the  ulnar,  are  generally  too  small  to  require  any  par- 
ticular attention  in  operations.  The  first  is  crossed  by  all  the 
extensor  tendons,  and  traverses  the  region  below  the  posterior 
annular  ligament ;  the  second,  already  pointed  out  in  the  pre- 
ceding region,  crosses  the  posterior  surface  of  the  ulna  obliquely, 
from  within  outwards  and  from  before  backwards,  so  that  it 
is  crossed  in  its  turn  by  the  tendons  of  the  extensor  carpi  ulnari* 
and  extensor  minimi  digiti. 

vi.  The  Veins. 

Those  which  appear  through  the  skin  are  generally  very  large  : 
their  number  varies  greatly,  but  they  are  usually  collected  inter- 
nally and  externally  in  order  to  form  two  principal  trunks ;  the 
internal,  most  constant  and  voluminous,  was  called  Salvatella, 
by  the  ancients  ;  the  external  is  chiefly  made  up  of  the  veins  of 
the  first  two  fingers,  and  constitutes  the  Cephalic  of  the  thumb. 
The  first  ascends,  under  the  name  of  ulnar,  and  the  second, 
under  that  of  radial,  behind  the  fore-arm.  Formerly,  venesec- 
tion was  often  performed  in  these  veins ;  but  at  present  we  sel- 
dom have  recourse  to  it,  unless  those  of  the  fold  of  the  arm  can- 
not answer  the  purpose. 

The  deep-seated  veins  present  nothing  particular. 

VH.  The  Lymphatics. 

These  vessels  pass  from  the  hand  and  fore-arm,  and  are  ar- 
ranged in  the  same  manner  as  in  these  regions :  they  do  not  pre- 
sent any  thing  requiring  particular  notice. 

viii.  The  Nerves. 

Some  filaments  of  the  cutaneous  nerves  of  the  brachial  plexu.> 
ramify  around  the  veins  and  terminate  in  the  superficial  layer  ot 


OF    THE    THORACIC    EXTREMITIES.  341 

the  dorsum  of  the  wrist.  We  also  observe  in  this  region  the 
posterior  branch  of  the  radial  nerve,  which  here  divides  into  an  in- 
ternal and  external  cord.  On  the  inner  side,  the  posterior  branch 
of  the  ulnar  nerve  bifurcates  in  like  manner:  their  different 
branches  creep  in  the  aponeurotic  layer,  and  cross  the  most  of 
the  tendons,  so  that  a  cutting  instrument  might  possibly  divide 
them,  without  involving  the  latter  ;  and  as  it  would  then  be  im- 
possible to  extend  the  fingers,  we  might  easily  be  mistaken  as  to 
the  nature  of  such  wounds. 

ix.  TJie  Skeleton. 

It  is  remarkable  for  the  number  of  bones  and  articulations 
which  enter  into  its  composition. 

Superiorly  and  transversely,  from  its  outer  to  its  inner  border, 
we  observe,  1st.  upon  the  radius,  different  crests  which  separate 
the  tendinous  sheaths :  these  crests  should  be  noticed,  as  they  are 
sometimes  so  prominent  that  they  might  posssibly  be  mistaken 
for  exostes ;  2d.  the  gutter  which  the  tendons  of  the  extensor 
communis  traverse,  and  wrhich  corresponds  internally  to  the 
radio-cubital  articulation  ;  3d.  the  head  of  the  ulna,  which  natur- 
ally makes  a  prominence  under  the  skin,  between  the  tendon  of 
the  extensor  minimi  digiti  and  that  of  the  extensor  carpi  ulnaris. 

Below  the  bones  of  the  fore-arm  there  is  a  narrow,  convex 
part,  representing  the  posterior  surface  of  the  bones  of  the  car- 
pus, and  which  unites  the  hand  to  the  fore-arm.  Superiorly,  this 
species  of  neck  presents  a  transverse  semi-circular  groove,  with 
superior  convexity,  which  corresponds  to  the  radio-carpal  articu- 
lation. This  groove  deserves  the  greatest  attention  when  we  am- 
putate the  wrist,  because,  if  the  knife  should  fall  below  it,  it 
would  enter  between  the  two  rows  of  the  bones  of  the  carpus ; 
if  above  it,  we  would  be  liable  to  denude  the  radius  and  ulna.  In 
order  to  find  it  and  penetrate  directly  into  the  joint,  or  rather  to 
perform  the  operation  in  question,  divers  methods  have  been  re- 
commended. In  one,  the  surgeon  makes  a  circular  incision 
through  the  skin  below  the  inferior  transverse  line  which  it  pre- 
sents in  the  anterior  region,  dissects  and  raises  it,  divides  the 
tendons,  and  then  removes  the  hand  by  traversing  the  articulation 
from  the  apex  of  the  external  styloid  process  to  the  internal,  in 


342 


OF   THE    THORACIC'    EXTREMITIES. 


the  direction  of  the  groove  just  indicated.  In  the  other,  having 
marked  the  anti-brachial  styloid  processes,  a  semi-lunar  incision 
with  inferior  convexity  is  made  through  the  integuments ;  the 
cellular  bridles  are  divided,  and  the  skin  drawn  up  by  an  assist- 
ant ;  the  posterior  tendons  are  then  cut  across,  and,  in  order  to 
disarticulate,  the  point  of  the  knife  is  passed  into  the  articulation, 
under  the  apex  of  the  styloid  process  of  the  radius,  and  makes  a 
semi-circular  incision,  in  an  inverse  direction  to  that  which  was 
made  through  the  skin ;  all  that  is  then  to  be  done  is  to  form  the 
anterior  flap,  which  is  the  principal,  taking  care  to  avoid  the  pisi- 
forme  and  the  crest  of  the  scaphoides.  If,  in  either  of  these  two 
methods,  we  carried  the  instrument  directly  across  from  one  sty- 
loid process  to  the  other,  we  would  separate  the  two  rows  of  the 
carpal  bones ;  by  following  the  curved  line  just  mentioned,  this 
error  will  always  be  avoided,  whether  the  incision  commences  at 
the  radial  or  cubital  border ;  it  is  more  sure,  however,  to  begin 
upon  the  outer  side,  because  the  scaphoides  is  more  inclined 
under  the  styloid  process  of  the  radius,  whilst  the  apex  of  that 
of  the  ulna  falls  exactly  on  a  level  with  the  articulation  of  the 
cuneiform  with  the  unciforme  bone. 

By  a  third  method,  the  instrument  is  carried  transversely  flat- 
wise, between  the  bones  and  the  soft  parts,  to  the  fore  part  of 
the  radio-carpal  articulation.  In  this  way  we  commence  by 
forming  the  anterior  flap,  which  we  raise;  then  we  make  an  in- 
cision upon  the  dorsal  surface  of  the  wrist,  as  in  the  preceding 
case,  and  the  disarticulation  is  effected  in  the  same  manner  as  by 
the  first  process. 

The  anatomical  disposition  of  the  parts  permits  the  belief 
that  we  may  succeed  by  either  of  these  methods  of  operating. 
The  first,  adopted  by  Sabatier  and  followed  by  most  English 
surgeons,  is  certainly  as  easy  and  certain  as  any  other :  it  even 
has  the  advantage  of  forming  a  more  regular  wound,  and  of  ren- 
dering the  apophyses  less  liable  to  remain  uncovered ;  but  it  is 
not  always  possible  to  cut  the  skin  so  low  as  to  admit  of  the  union 
of  the  soft  parts  by  the  first  intention. 

The  second  is  more  expeditious,  and  as  we  may  give  much 
length  to  the  flaps,  especially  to  the  anterior,  an  immediate  re- 
union will  readily  take  place.  We  must  mention,  however,  that 
as  the  skin  is  not  of  so  great  a  length  at  the  angles  of  the  wound. 


OF    THE    THORACIC    EXTREMITIES.  343 

it  is  more  difficult  to  cover  the  bones  exactly,  which  are  larger 
and  more  prominent  in  this  situation  than  in  the  middle.  Lastly, 
the  third,  which  appertains  to  M.  Lisfranc,*  presents  nearly  the 
same  advantages,  and  may  also  be  followed  by  the  same  in- 
conveniences. 

It  should  also  be  observed,  that  in  the  first  method,  the  dissec- 
tion of  the  skin,  which  is  easy  upon  the  dorsal  surface,  requires 
caution  upon  the  palmar  surface,  on  account  of  the  compact  tex- 
ture of  the  cellular  tissue,  and  that  this  reason  alone  should  pre- 
vent us  from  commencing  the  operation  at  the  anterior  part,  by 
the  flap  method,  even  when  there  are  sufficient  soft  parts  behind 
to  cover  the  osseous  extremities. 

As  the  articulatory  surfaces  of  the  bones  of  the  fore-arm  are 
so  disposed  that  they  form  a  very  deep  transverse  concavity,  and 
as  their  apophyses  are  about  two  inches  and  a  half  asunder, 
whilst  the  antero-posterior  diameter  of  the  radius  is  not  more 
than  an  inch  ;  the  radio  and  cubito-carpal  ligaments  being  also  very 
strong,  it  follows  that  internal  or  external  luxations  of  the  wrist 
must  be  very  rare,  and  that  they  cannot  be  complete  without  the 
previous  laceration  of  numerous  parts.  On  the  other  hand,  as 
the  corresponding  articular  surface  of  the  bones  of  the  carpus  is 
pretty  regularly  convex,  we  cannot  easily  comprehend  how  in- 
complete carpal  luxations  can  occur  in  either  of  these  direc- 
tions ;  behind  and  before,  on  the  contrary,  the  osseous  margin 
is  scarcely  prominent,  and  the  ligaments  only  can  oppose  some 
resistance  to  the  displacements,  which  are  likewise  favoured  by 
the  natural  movements  of  the  hand.  We  have  already  men- 
tioned in  what  manner  the  luxation  forwards  is  effected :  the 
opposite  displacement  is  produced  by  the  same  mechanism  ;  but 
it  is  more  rare,  because  the  osseous  extremities  are  less  disposed 
to  slip  in  the  latter  direction,  and  because  the  hand  turns  less 
easily  forwards  than  backwards. 

The  same  cause  which  occasions  the  luxation  of  the  head  of 
the  ulna  forwards,  in  forced  stipulation,  will  also  produce  its 
luxation  backwards,  in  pronation,  when  the  head  of  the  radius  is 
solidly  maintained  upon  the  hurnerus. 

We  would  observe,  finally,  that  the  two  bones  of  the  fore-arm 

*  Coster's  Manual  of  Surgical  Operations,  &c.,  Godman's  translation,  p,  48. 


314 


01     THE    THORACIC    EXTREMITIES. 


may  be  separated  by  those  causes  which  would  tend  to  produce 
lateral  luxations,  and  that  this  species  of  diastasis  is  pretty  frequent, 
even  in  fractures  of  the  inferior  extremity  of  the  ulna  and  radius. 

With  respect  to  the  bones  of  the  carpus,  they  afford  too  slight 
a  hold  for  the  action  of  external  powers,  their  ligaments  are  too 
numerous  and  firm,  to  permit  their  luxation  upon  each  other. 
There  is  one,  however,  which  is  less  solidly  encased,  the  rounded 
head  of  which  is  susceptible  of  being  driven  from  the  cavity 
which  encloses  it ;  this  is  the  os  magnum  :  as  it  is  thicker  poste- 
riorly than  anteriorly,  the  displacement  always  occurs  in  the 
former  direction ;  at  least  this  is  the  observation  of  Chopart  and 
Boyer.  Among  the  carpo- metacarpal  articulations,  the  h'rst  only 
admits  of  luxation.  In  fact,  it  is  isolated  from  the  others,  and  its 
surfaces  are  enveloped  by  a  species  of  capsule,  which  is  suffi- 
ciently loose  to  accommodate  them  to  the  movements  of  the 
thumb ;  but  it  is  almost  impossible  for  this  accident  to  take  place 
forwards,  on  account  of  the  muscles  of  the  thenar  eminence  ;  or 
inwards,  on  account  of  the  facet  of  the  os  trapezium  which  looks 
outwards  and  forwards,  and  which  permits  the  abduction  to  be 
carried  very  far  without  the  surfaces  abandoning  each  other ; 
finally,  or  directly  outwards,  because  in  adduction  the  thumb  is 
soon  stopped  by  the  metacarpal  bone  of  the  indicator.  Poste- 
riorly and  externally,  however,  the  first  metacarpal  bone  is  cov- 
ered only  by  the  skin,  an  aponeurotic  expansion  of  but  slight 
strength,  and  the  fibrous  capsule,  which  is  also  weaker  in  this 
direction ;  besides,  the  articular  facets  are  less  extensive  from 
before  backwards  than  transversely,  and  the  movement  of  oppo- 
sition is  that  which  the  thumb  most  frequently  executes.  The 
only  resistance  then  to  the  cause  of  displacement  is  afforded  by 
the  extensor  tendons  of  the  thumb.  As  for  the  rest,  this  articu- 
lation is  easily  felt  through  the  integuments,  in  the  summit  of  the 
fossette  situated  behind  it.  We  will  have  occasion  to  revert  to 
this,  however,  when  speaking  of  the  hand,  in  relation  to  the  am- 
putation of  the  thumb. 

Although  the  articulation  of  the  fifth  metacarpal  bone  with  the 
os  unciforme  is  so  disposed  as  to  admit  of  some  motion,  yet  it  is 
not  so  moveable  as  to  permit  its  luxation ;  but  it  deserves  notice, 
on  account  of  the  operations  which  are  performed  upon  it.  Its 
surfaces  are  plane  and  slightly  oblique  inwards ;  its  dorsal  and 


OP   THE    THORACIC    EXTREMITIES.  345 

palmar  transverse  ligaments  are  strong,  and  must  be  divided 
when  we  adopt  the  method  of  M.  Lisfranc,  before  we  attempt  to 
depress  the  bone  and  introduce  the  point  of  the  instrument  into 
the  joint. 

With  respect  to  the  three  other  articulations,  they  are  almost 
entirely  immoveable.  We  should  observe,  however,  that  the 
posterior  extremity  of  the  second  metacarpal  bone  is  surmounted 
by  two  processes  which  are  prolonged  upwards  for  the  inser- 
tions of  the  flexor  carpi  radialis  and  extensor  carpi  radialis 
longior,  and  that  the  third  presents  a  similar  prolongation  for  the 
extensor  carpi  radialis  brevoir,  which  would  render  their  disar- 
ticulation  more  difficult. 

In  the  dorsal  region  of  the  wrist  the  different  organic  strata 
are  arranged  in  the  following  order:  1st.  The  skin;  2d.  the 
cellular  layer ;  containing  the  superficial  veins  and  nerves ;  3d  the 
aponeurosis  and  annular  ligament ;  4th  branches  of  the  radial  and 
ulnar  nerves  ;  5th  the  tendons  and  their  synovial  envelopes  ;  6th 
the  deep  seated  arteries  and  veins ;  7th  the  bones  and  their  liga- 
ments. 

ART.  VI.    OF    THE    HAND. 

The  hand  is  comprised  between  the  inferior  limits  of  the  wrist 
and  the  roots  of  the  fingers ;  it  forms  an  irregular  square,  and  is 
divided  by  the  acromio-digital  and  sub-scapulo-digital  lines,  into 
the  anterior  or  palmar  region,  and  the  posterior  or  dorsal  region. 

Sect.  I.  The  Palmar  Region. 

It  is  more  extensive  than  the  dorsal  region,  and  is  prolonged 
some  lines  backwards  upon  the  wrist,  and  forwards  upon  the  artic- 
ulation of  the  fingers.  Upon  its  surface  we  observe,  1st.  ex- 
ternally, a  muscular  prominence,  the  apex  of  which  terminates  at 
the  thumb ;  this  is  the  thenar  eminence ;  2d.  internally,  another 
eminence  longer,  but  narrower,  extending  posteriorly  as  far  as 
the  os  pisiforme :  this  is  the  hypothenar  eminence  ;  3d.  anteriorly, 
when  the  four  fingers  are  approximated,  three  risings  formed  by 
the  skin,  which  correspond  to  the  intervals  of  the  digital  roots ; 
1th.  in  the  same  position,  three  grooves  which  separate  these  last 

44 


346  OF    THE    THORACIC    EXTREMITIES. 

prominences;  5th.  in  the  middle,  an  excavation  terminating  ex- 
ternally and  posteriorly  in  the  indicator  on  the  one  part,  and 
which  is  continuous  with  the  median  groove  of  the  wrist,  on  the 
other ;  this  is  the  hollow,  or  palm  of  the  hand ;  6th  in  this  hollow 
several  lines  are  observed  which  are  pretty  constant ;  one  takes 
its  origin  from  the  anterior  and  external  extremity  of  the  palmar 
gutter,  and  almost  immediately  bifurcates  in  such  a  manner  that 
the  first  of  its  branches  makes  a  semi-circular  turn  in  order  to 
circumscribe  the  thenar  eminence,  whilst  the  second  passes  at  first 
transversely  and  afterwards  forms  a  semi-lunar  curve  in  order  to 
terminate  upon  the  posterior  part  of  the  hypothenar  eminence  ; 
another  line  seems  to  originate  from  the  place  where  the  first 
terminated,  that  is  to  say  from  the  wrrist,  and  descends  vertical- 
ly upon  the  middle  of  the  preceding ;  finally  a  third  extends  from 
the  interval  which  separates  the  indicator  from  the  medius,  to  the 
base  of  the  little  finger,  cutting  the  hypothenar  eminence  into  two 
unequal  portions.  Its  convexity  looks  backwards  and  outwards, 
so  that,  united  with  the  line  of  the  indicator,  it  somewhat  resem- 
bles an  X  with  lengthened  branches.  Each  of  these  three  fur- 
rows appear  to  be  produced  by  particular  movements ;  thus  the 
first  is  owing  to  the  movement  of  opposition  of  the  thumb  and 
may  be  called  the  thumb  line ;  the  second,  to  the  flexion  of  the 
other  fingers,  in  conjunction  with  that  of  the  thumb  when  we  wish 
to  grasp  a  cylindrical  body,  for  example,  and  we  may  name  it  the 
indicator  line :  the  third  seems  to  depend  upon  the  momentary 
extension  of  the  index  finger  whilst  the  others  are  flexed  upon 
any  body  whatsoever ;  this  is  the  line  of  the  little  finger.  By 
uniting  the  transverse  portion  of  the  last  two,  we  have  a  furrow 
crossing  the  fore  part  of  the  hand  about  three  lines  behind  the 
metacarpo-phalangeal  articulation,  which  might  be  called  the 
metacarpal furrow.  These  different  creases  require  attention  when 
it  becomes  necessary  to  make  incisions  into  the  hand. 

CONSTITUENT    PARTS. 

i.   The  Skin. 

It  is  generally  very  thick  throughout  the  whole  extent  of  this 
region,  but  preserves  a  certain  degree  of  suppleness  upon  the 


OF   THE   THORACIC    EXTREMITIES.  347 

thenar  eminence ;  elsewhere  it  is  dense,  compact,  and  almost 
inextensible ;  it  is  destitute  of  hairs  and  sebaceous  follicles.  In 
labouring  people,  the  natural  polish  of  its  surface  is  changed  into 
rough  callosities,  which  increase  its  thickness,  and  render  inflam- 
mations of  this  part  among  them  more  severe  and  dangerous. 

In  addition  to  the  lines  indicated  above  we  find  a  great  many 
others  which  are  owing  to  the  arrangement  of  the  papillae  of  the 
corpus  mucosum.  These  papillary  lines  are  so  disposed  that, 
upon  the  thenar  eminence  they  form  curves,  the  concavity  of 
which  is  towards  the  thumb,  whilst,  upon  the  hypothenar,  they 
are  circular  in  its  posterior  half,  and  almost  transverse  anteriorly. 
Those  of  the  hollow  of  the  hand  diverge  as  they  approach  the 
intervals  of  the  fingers,  in  such  a  manner  as  to  receive  in  their 
span  the  convexity  of  the  small  groupe  of  curved  lines  in  the 
vicinity  of  the  roots  of  the  digital  appendices.  The  skin  of 
cicatrices  presents  nothing  analogous  to  this  arrangement. 

ii.  The  Superficial  Layer. 

Before  the  head  of  the  metacarpal  bones,  and  upon  the  hy- 
pothenar eminence,  this  layer  consists  of  a  very  dense  filament- 
ous cellular  tissue,  which  unites  the  deep-seated  textures  solidly 
to  the  skin,  and  contains  a  great  number  of  small  adipose  vesicles. 
This  structure  constitutes  a  species  of  elastic  cushion,  which  varies 
but  little  in  thickness,  and  is  prolonged  upon  the  fingers.  Upon 
the  thenar  eminence,  the  cellular  tissue  is  rather  lamellated  than 
filamentous,  and  consequently  unites  the  aponeurosis  less  firmly 
to  the  skin ;  whence  also  it  follows  that  the  phenomena  of  its 
inflammations,  abscesses,  and  Rumours  differ  but  little  from  those 
in  other  parts  of  the  body,  whilst,  in  the  rest  of  the  region,  the 
compact  texture  of  the  parts  gives  rise  to  very  severe  symptoms. 
In  the  hollow  of  the  hand  this  layer  is  much  thinner ;  the  fila- 
ments and  lamellae  are  more  approximated  and  blended,  as  it 
were,  with  the  aponeurosis  and  the  skin :  it  no  longer  contains 
adipose  vesicles,  and  consequently  no  elastic  cushion. 

HI.  The  Aponeurosis. 
In  the  palmar  excavation  this  fascia  is  at  first  very  strong,  after- 


348  OP   THE   THORACIC    EXTREMITIES. 

wards  it  becomes  gradually  thinner  externally,  forming  only  a 
simple  cellular  lamina  upon  the  thenar  eminence,  where  it  is  lost 
in  the  preceding  layer.  As  it  passes  towards  the  inner  border  of 
the  hand,  it  also  becomes  more  attenuated,  and  gives  origin  to 
the  palmaris  brevis  muscle.  If  we  trace  it  towards  the  wrist, 
we  will  find  that  it  is  only  a  continuation  of  the  tendon  of  the 
palmaris  longus  and  ligamentum  carpi  annulare  anterius ;  the 
diverging  fibres  of  the  former  and  the  transverse  of  the  latter, 
although  pretty  intimately  intermingled,  are  nevertheless  distinct 
where  the  aponeurosis  is  strongest.  As  it  approximates  the  an- 
terior part  of  the  hand,  those  of  the  palmaris  longus  are  collected 
into  four  diverging  bandalets  which  bifurcate  in  order  to  embrace 
the  root  of  each  finger,  applying  themselves  upon  the  flexor  ten- 
dons, or  rather  becoming  blended  with  the  thecse  of  these  tendons. 
Those  of  the  annular  ligament  or  the  transverse  fibres,  become 
less  and  less  distinct  in  proportion  as  they  advance,  and  soon  form 
only  small  arcs  of  circles,  which  also  apply  themselves  upon  the 
tendons,  before  they  reach  the  first  phalanx,  and  in  this  manner 
seem  insensibly  to  give  origin  to  the  thecse  of  the  tendons. 

In  the  palmar  aponeurosis  there  are  various  apertures  formed 
by  the  separation  of  its  fibres  at  the  place  of  their  intersection. 
Some  of  these  openings  are  very  small,  others  of  considerable 
size ;  becoming  larger  and  more  numerous  towards  the  fingers : 
they  are  filled  with  cellular  tissue  or  fatty  processes,  by  means 
of  which  a  communication  is  formed  between  the  superficial  and 
deep-seated  parts.  These  foramina  seem  to  concur  in  producing 
those  acute  pains  consequent  upon  inflammations  in  the  hollow 
of  the  hand,  by  the  strangulation  of  the  tumefied  parts  which 
their  margins  must  produce ;  and  hence  the  necessity  of  enlar- 
ging them  early  in  these  diseases. 

iv.  The  Muscles. 

Some  appertain  to  the  thenar  eminence,  others  to  the  hypothe- 
nar  eminence ;  the  palm  of  the  hand  also  has  its  distinct  mus- 
cles. 

The  first  constitute  the  external  muscular  mass,  and  are : — 1st. 
the  abductor  brevis,  which  especially  covers  the  carpo-metacarpal 
articulation  of  the  thumb,  and  which  is  there  strengthened  by 


OF    THE    THORACIC    EXTREMITIES.  349 

the  tendon  of  the  abductor  longus ;  this  is  one  of  those  which 
most  strongly  oppose  the  luxation  of  the  first  metacarpal  bone 
forwards ;  2d,  the  flexor  brevis  and  opponens  pollicis,  which  also 
prevent  the  displacement  in  the  same  direction  aud  inwards,  not 
by  applying  themselves  upon  the  joint,  but  by  acting  upon  the 
bone  as  upon  a  lever  of  the  third  order ;  as  they  are  fixed  very 
far  from  the  point  of  support,  they  must  act  with  much  force ; 
3d,  the  adductor  pollicis,  a  fan-like  muscle,  placed  transversely, 
which  acts  in  the  same  direction  as  the  last  two  in  opposing  lux- 
ations, especially  inwards ;  indeed  it  resists  still  more  powerfully, 
because  it  is  inserted  at  a  right  angle  into  the  bone  which  the 
force  tends  to  throw  backwards. 

The  second  form  the  internal  muscular  prominence.  In  ii 
we  find,  first,  in  the  cellular  layer,  the  palmaris  brevis,  stretched 
over  the  superior  fourth  of  the  aponeurosis,  which  it  fixes  to  the 
internal  surface  of  the  skin,  towards  the  ulnar  margin  of  the 
hand :  it  is  this  which  produces  that  small  depression  observed 
within  and  below  the  os  pisiforrne  when  the  thumb  and  little  fin- 
ger are  brought  into  forcible  adduction ;  next  the  adductor  (ab- 
ductor minimi  digiti)  attached  to  the  os  pisiforme,  and  apparently 
continuous  with  the  tendon  of  the  flexor  carpi  ulnaris :  therefore, 
when  the  little  finger  is  thrown  into  adduction,  the  latter  tendon 
is  rendered  very  tense ;  finally,  the  flexor  parvus,  vel  proprius 
minimi  digiti,  which  is  frequently  confounded  with  the  preceding ; 
and  deeper  still  the  abductor  (opponens  minimi  digiti),  which  is 
one  of  the  palmar  interossei. 

Those  of  the  palm  are  the  lumbricales,  which  can  only  be 
considered  as  appendages  to  the  tendons  of  the  flexor  profundus, 
favouring  their  action  upon  the  fingers  by  their  insertion  into  the 
dorsal  surface  of  the  first  phalanges ;  and  the  first  two  palmar 
interossei  which  present  nothing  peculiar. 

Besides  these  different  muscular  bundles,  all  the  flexor  tendons 
of  the  fingers  pass  through  this  region ;  we  consequently  find  in 
it  the  four  tendons  of  the  flexor  sublimis,  as  well  as  those  of  the 
profundus,  all  of  which  diverge  towards  the  metacarpo-phalangeal 
articulations,  where  they  enter  into  their  sheaths.  That  of  the 
thumb  slides  between  the  two  portions  of  the  flexor  brevis  mus- 
cle, and  also  passes  on  to  its  theca.  Under  the  aponeurosis,  all 
these  tendons  are  enveloped  collectively  and  separately  by  a, 


350  OF    THE    THORACIC    EXTREMITIES. 

synovial  membrane,  entirely  similar  to  that  of  the  wrist,  of  which 
it  is  only  the  continuation.  This  membrane  is  liable  to  the  same 
diseases,  which  are  attended  with  equal  and  even  greater  danger, 
on  account  of  the  resistance  made  by  the  fascia  to  the  inflam- 
matory tumefaction  of  the  parts. 

v.  The   Arteries. 

The  ulnar  and  radial  arteries  terminate  here,  forming  two 
arcades  called  "  palmar  arches."     One  of  these  arcades  is  super- 
ficial, and  is  situated  between  the  aponeurosis  and  the  skin ;  its 
convexity  looks  downwards,  and  it  is  found  about  sixteen  lines 
below  the  annular  ligament ;  its  external  extremity  is  continu- 
ous with  the  radial  artery,  through  the  root  of  the  thenar  emi- 
nence.    On  this  side  the  superficial  palmar  arch  is  small,  unless 
the  artery  gives  off  a  larger  anterior  branch  than  usual.     Inter- 
nally, it  passes  towards  the  ulnar  artery,  of  which  it  is  the  con- 
tinuation, and  consequently  its  volume  is  greater  than  externally ; 
we  find  it  directly  upon  the  radial  side  of  the  os  pisiforme,  and 
in  order  to  follow  its  direction  it  is  easy  to  imagine  a  semicircle 
sixteen  lines  in  depth,  the  extremities  of  which  would  rest  upon 
the  pisiforme  and  the  crest  of  the  scaphoides.     According  to 
this  disposition,  we  perceive  that  this  arch  is  very  liable  to  be 
wounded,  in  which  case  it  would  be  very  difficult  to  secure  it  in 
the  situation  of  the  wound,  on  account  of  the  compact  texture 
of  the  tissues.     If  we  wished  to  operate  immediately,  it  would 
be  necessary  to  tie  both  the  radial  and  ulnar  arteries  ;  but  this  is 
not  always  necessary,  for  the  aponeurosis  affords  so  much  re- 
sistance, that  compression  will,  generally,  succeed  in  arresting 
the  haemorrhage.     Four  principal  digital  arteries  originate  from 
the  convexity  of  this  arch,  which  pass -onwards  to  bifurcate  at  the 
base  of  the  fingers,  in  the  interval  of  the  fibrous  bandelets  of  the 
aponeurosis  ;  it  also  gives  off  several  considerable  branches  which 
ramify  in  the  thenar  and  hypothenar  eminences ;  so  that  through- 
out the  whole  palmar  surface  of  the  hand,  the  skin  and  superficial 
layer  receive  large  and  numerous  arteries,  or  give  passage  to 
these  vessels. 

The  deep  palmar  arch  is  less  curved  than  the  superficial ;  its 
convexity  is  directed  a  little  inwards  and  backwards ;  it  lies  be- 


OP    THE    THOU  A  C1C    EXTREMITIES.  351 

tween  the  flexor  tendons  and  the  interossei  muscles ;  its  internal 
extremity  originates  from  the  ulnar  artery,  of  which  it  forms  the 
deep  branch.  As  this  branch  separates  from  the  trunk  it  passes 
through  the  posterior  extremity  of  the  flexor  parvus  minimi  dig- 
iti,  in  order  to  get  behind  the  tendons.  The  other  extremity 
passes  between  the  adductor  and  flexor  brevis  pollicis  muscles, 
into  the  posterior  part  of  the  first  interosseous  space,  where  it 
communicates  with  the  radial  artery,  to  which  it  actually  belongs, 
and  which  also  furnishes  two  very  large  deep  branches  to  the 
muscles  of  the  thenar  eminence,  along  the  ulnar  side  of  the  first 
metacarpal  bone,  and  the  radial  border  of  the  second.  The 
convexity  of  the  deep  palmar  arch  gives  off  four  or  five  small 
branches  which  follow  the  direction  of  the  interosseal  spaces,  and 
which  communicate,  near  the  head  of  the  metacarpal  bones,  with 
twigs  from  the  dorsal  artery  of  the  metacarpus ;  this  arch  also 
distributes  forwards,  backwards,  and  from  its  concavity,  several 
other  ramuscules  which  anastamose  with  the  superficial,  dorsal, 
etc.,  arteries. 

From  the  arrangement  of  these  two  arches  it  follows,  that  all 
the  arteries  of  the  hand  communicate  extensively  with  each  other, 
and  that  the  ulnar  and  radial  form  a  very  long  loop,  which  is 
double  inferiorly,  where  its  base  is,  single  in  the  fore-arm,  where  it 
is  prolonged  to  the  brachial  trunk.  Therefore,  when  one  of  the 
branches  of  this  loop  is  wounded,  we  cannot  effectually  arrest 
the  haemorrhage  without  applying  a  thread  upon  each  divided 
extremity  of  the  artery ;  and  when  they  are  the  seat  of  a  spon- 
taneous aneurism,  it  is  prudent  to  put  a  ligature  above  and  below 
the  vessel. 

We  have  seen  a  specimen  in  the  possession  of  Prof.  Beclard 
in  which  all  the  arteries  of  the  fore-arm  and  hand  were  exces- 
sively dilated,  and  their  tunics  at  the  same  time  very  much  thick- 
ened. The  palmar  arches  formed  a  very  complicated  plexus, 
since  all  the  branches  were  of  the  size  of  a  goose-quill ;  they 
were  tortuous,  undulated ;  finally,  their  disposition  was  precisely 
similar  to  that  of  those  large  varicose  knobs  frequently  observed 
upon  the  vena  saphena :  indeed,  we  might  say,  that  these  arte- 
ries were  in  a  state  of  hypertrophy.  It  is  unnecessary  to  observe 
that  in  the  subject  to  whom  this  specimen  orginally  belonged,  the 


.i..v.  OP    THE    THORAdl     EXTREMITIES. 

slightest  wound  in  the  palm  of  the  hand  would  have  occasioned 
a  dangerous  haemorrhage. 

vi.  The  Veins. 

Upon  the  thenar  eminence  the  superficial  veins  still  preserve 
a  certain  volume ;  they  are  smaller  upon  the  hypothenar  emi- 
nence and  still  smaller  in  the  palmar  hollow ;  they  follow  the 
distribution  of  the  superficial  arch,  and  enter  the  anterior  veins 
of  the  wrist.  • 

The  deep-seated  accompany  all  the  branches  of  the  corres- 
ponding arterial  arch,  and  pass  into  the  deep  radial  and  ulnar 
veins.  These  vessels  have  no  relation  with  operations. 

vn.  The  Lymphatics. 

The  superficial  form  three  or  four  trunks,  which  are  generally 
met  with  upon  the  fore  part  of  the  muscles  of  the  thumb  and 
which  pass  to  the  anterior  aspect  of  the  wrist.  The  deep  lym- 
phatics are  in  contact  with  the  arteries,  communicate  with  the 
superficial  set,  and  equally  pass  to  the  fore-arm. 

VITI.  The  Nerves. 

We  meet  with,  upon  the  thenar  eminence,  some  superficial 
twigs  from  the  radial,  and  filaments  from  the  small  cutaneous 
palmar  branch  of  the  median  are  distributed  in  the  cellular  layer 
of  the  palm  of  the  hand ;  the  hypothenar  receives  the  two  ter- 
minating branches  of  the  ulnar.  These  last  two  cords  separate 
on  a  level  with  the  pisiforme,  on  the  outer  side  of  which  their 
common  branch  is  situated  like  the  artery  which  it  accompanies. 
The  first  passes  to  the  last  two  fingers,  applied  upon  the  muscles 
of  the  internal  eminence,  and  covered  by  the  fatty  cushion  and 
palmaris  brevis  muscle.  In  its  course  it  leaves  one  or  more 
branches  upon  the  internal  part  of  the  hypothenar.  The  second 
passes  through  the  posterior  extremity  of  the  opponens  and  flexor 
parvus  minimi  digiti  muscles,  on  the  inner  side  of  the  hook  ol 
the  os  unciforme,  and  forms  an  arch  upon  the  fore  part  of  the 


OP   THE    THORACIC    EXTREMITIES. 

mterossei  muscles,  like  the  deep  arterial  arch.  It  would  seem 
that  this  branch  appertains  to  the  muscles,  whilst  the  preceding 
is  chiefly  distributed  to  the  skin.  Be  this  as  it  may,  it  is  easy  to 
perceive  that  the  ulnar  eminence  of  the  hand  is  much  more  abun- 
dantly supplied  with  nerves  than  the  radial,  and  consequently 
that  its  diseases  must  be  attended  with  much  more  acute  pain. 
Finally,  the  median  terminates  in  this  region  in  giving  origin  to 
four  or  five  large  branches,  which  diverge  as  they  pass  onwards, 
and  bifurcate  at  the  roots  of  the  first  four  fingers.  All  these 
branches  lie  under  the  fascia,  running  between  it  and  the  ten- 
dons of  the  sublimis ;  previous  to  reaching  the  fingers  they  only 
give  a  small  filament  to  each  lumbricalis  muscle. 

ix.  The  Skeleton. 

It  represents  a  species  of  grate  (grillage),  concave  transverse- 
ly and  from  before  backwards,  formed  by  the  anterior  face  of  the 
five  bones  of  the  metacarpus,  the  intervals  between  which  are 
broader  than  upon  the  posterior  aspect.  The  transverse  concav- 
ity of  the  metacarpus  is  occasioned  by  the  posterior  extremities 
of  the  bones  being  cut  in  the  form  of  as  many  small  wedges,  the 
edges  of  which  are  turned  forwards,  and  also  to  the  carpal  row 
which  corresponds  to  them  being  likewise  concave.  Its  antero- 
posterior  curvature  depends  upon  its  proper  bones,  and  proceeds 
from  the  expansion  of  their  phalangeal  extremity  anteriorly  and 
laterally,  and  it  is  also  in  consequence  of  this  disposition  that  the 
interosseous  spaces  are  broader  in  the  middle  than  before  and  es- 
pecially than  behind.  In  the  latter  direction,  the  bones  of  the 
metacarpus  are,  as  has  been  already  mentioned,  very  solidly  fix- 
ed ;  but  their  head,  or  their  anterior  extremity,  is  only  maintained 
by  means  of  the  transverse  metacarpal  ligament,  before  which 
the  tendons,  nerves,  and  arteries  of  the  superficial  arch  run, 
whilst  the  interossei  muscles  pass  behind  them.  We  will  recur  to 
the  peculiarities  which  relate  to  these  bones,  in  the  dorsal  region, 
when  we  come  to  speak  of  the  amputations  of  some  of  them. 

The  following  is  the  order  of  superposition  of  the  different  or- 
gans examined  in  the  palmar  region :  1st,  the  skin ;  2d,  the  super- 
ficial layer,  including  the  ulnar  palmar  arch,  a  part  of  the  ulnar 
nerve,  and  the  palmaris  brevis  muscle  ;  3d.  the  aponeurosis  :  4th, 

45 


354  Or    THE    THORACIC    EXTREMITIES. 

the  branches  of  the  median  nerve  ;  5th,  the  muscles  of  the  in- 
ternal and  external  eminences ;  the  tendons  of  the  flexors,  the 
lumbricales  ;  6th,  the  radial  palmar  arch ;  the  deep  branch  of  the 
ulnar  nerve,  the  interossei  interni  muscles  ;  7th,  the  bones. 

Sect.  2.  The  Dorsal  Region. 

It  is  less  complicated  than  the  preceding,  and  its  surface  pre- 
sents, when  the  fingers  are  extended  and  separated,  1st,  five 
cords,  which  converge  towards  the  wrist,  produced  by  the  tension 
of  the  extensor  tendons ;  2d,  three  grooves  between  these  ten- 
dons, which  increase  in  breadth  as  they  pass  to  their  termination 
at  the  origin  of  the  fingers ;  3d,  externally,  when  the  thumb  is  in 
adduction,  a  prominence  which  depends  upon  the  first  dorsal  in- 
terosseous  muscle,  and  behind  which  is  observed  the  excavation  of 
the  indicator,  which  was  mentioned  when  on  the  dorsal  surface  of 
the  wrist;  4th  in  the  anterior  part  of  this  fossette,  behind  the  mus- 
cular eminence,  when  the  thumb  is  in  abduction  and  opposition, 
we  readily  feel  the  posterior  extremity  of  the  first  two  metacar- 
pal  bones,  separated  by  a  notch  several  lines  in  breadth,  in  the 
bottom  of  which  we  find  the  radial  artery  at  the  instant  it  is  about 
to  penetrate  into  the  palmar  region  in  order  to  form  the  deep 
palmar  arch  ;  5th,  anteriorly,  when  the  hand  is  shut,  the  eminen- 
ces produced  by  the  metacarpal  heads,  the  most  prominent  of 
which  supports  the  middle  finger. 

CONSTITUENT  PARTS. 

i.  The  Skin. 

It  differs  but  little  from  that  of  the  corresponding  regions  of 
the  wrist  and  fore-arm  ;  its  thickness  is  greater  towards  the  sides 
than  upon  the  middle  of  the  back  of  the  hand ;  near  the  ulnar 
border,  it  is  covered  with  hairs,  and  contains  numerous  sebaceous 
follicles  ;  it  becomes  polished  as  it  approximates  the  fingers,  and 
presents  numerous  superficial  wrinkles  which  intersect  one  anoth- 
er in  various  directions. 


OF   THE    THORACIC    EXTREMITIES.  355 


ii.  The  Subcutaneous  Layer. 

This  lamina  is  very  thin  and  very  supple,  and  contains  but  few 
or  no  adipose  cells  ;  its  characters  are  the  same  as  in  the  wrist ; 
it  encloses  the  superficial  veins,  nerves,  etc. 

HI.  The  Aponeurosis. 

The  fibrous  sheet  of  the  back  of  the  hand  is  thin,  and  rather 
cellular  than  truly  aponeurotic ;  its  fibres  are  transverse  and 
seem  to  originate  from  the  annular  ligament ;  in  passing  towards 
the  fingers,  it  frequently  contracts  adhesions  with  the  tendons,  be- 
comes thicker,  stronger,  more  distinct,  and  is  lost  anteriorly  in 
the  cellular  tissue.  A  second  lamina  of  a  similar  nature  covers 
the  posterior  surface  of  the  bones  and  interossei  muscles.  This 
deep  lamina  is  blended  with  the  superficial  near  the  metacarpo- 
phalangeal  articulations  ;  posteriorly,  with  the  ligaments  of  the 
carpus,  and  laterally  again  with  the  superficial  aponeurosis  :  so 
that  between  these  two  sheets  the  tendons  and  principal  nerves 
are  found,  and  that,  in  inflammations  and  suppurations,  the  deep 
lamina  opposes  the  passage  of  the  disease  or  its  products  into  the 
palm  of  the  hand,  whilst  the  superficial  hinders  them,  for  some 
time,  from  making  a  visible  and  circumscribed  prominence  under 
the  skin. 

iv.  The  Tendons  and  Muscles. 

The  tendons  are  seven  in  number :  one  for  the  thumb,  two  for 
the  index,  two  for  the  little,  and  two  others  for  the  ring  and  middle 
fingers.  These  different  tendons  have  not  the  same  form ;  that 
of  the  thumb  is  narrow  and  cylindrical ;  those  of  the  indicator, 
that  of  the  extensor  proprius  minimi  digiti,  frequently  consist  of 
two  bandelets,  which  expand  over  the  metacarpo-phalangeal  ar- 
ticulation, and  are  blended  with  the  tendon  which  each  receives 
from  the  extensor  communis  :  those  of  the  indicator,  placed  one 
behind  the  other,  are  usually  spread  out  in  the  form  of  a  ribbon. 
All  these  tendons  send  off  processes  from  their  borders,  which, 
with  the  tendons  of  the  little  finger,  form  a  membrane  on  the 


356  OF   THE    THORACIC    EXTREMITIES. 

back  of  the  hand,  resembling  a  duck's  foot.  This  disposition  sat- 
isfactorily accounts  for  the  greater  or  less  facility  with  which  we 
can  move  this  or  that  finger.  Thus,  the  indicator,  the  thumb,  the 
little  finger,  extend  and  move  very  well,  though  the  others  remain 
in  a  state  of  inaction,  because  each  receives  several  tendons,  one 
of  which  at  least  does  not  depend  upon  the  common  extensor ; 
the  movements  of  the  middle  and  ring  finger,  on  the  contrary, 
are,  if  I  may  so  say,  tied  to  those  of  the  little  finger  and  indi- 
cator ;  and  the  extension  of  the  fourth  finger  is  impossible  dur- 
ing the  flexion  of  the  third,  because  there  exists  between  their 
tendons  too  intimate  a  connexion. 

The  synovial  membrane  which  lines  their  anterior  surface,  does 
not  form  for  them  a  particular  bursa.  Thinner  and  less  distinct 
than  that  of  the  flexor  tendons,  it  is  nevertheless  more  frequently 
the  seat  of  synovial  ganglions,  which  we  have  frequently  seen 
very  large,  becoming  inflamed,  bursting,  and  giving  rise  to  fistu- 
lous  ulcers.  These  tumours  may  be  limited  to  a  single  finger,  or 
extend  to  all,  to  the  wrist,  and  thus  cover  the  entire  dorsum  of 
the  hand  ;  and,  when  increased  to  this  degree,  if  they  inflame, 
they  will  seldom  be  cured  without  serious  symptoms ;  indeed? 
we  are  frequently  obliged  to  amputate  the  member.  We  are, 
however,  acquainted  with  a  medical  student  who  has  long  had  a 
similar  disease  ;  the  greater  part  of  the  knobs  which  it  formed 
suppurated ;  several  have  been  opened,  with  the  bistoury,  upon 
the  wrist,  the  root  of  the  thumb,  metacarpus,  etc.  Numerous 
leeches  have  been  applied,  at  different  intervals ;  the  whole  of 
the  affected  part  no  longer  formed  but  a  spongy  mass,  from  the 
inferior  fourth  of  the  fore-arm  to  the  middle  of  the  fingers. 
Several  celebrated  surgeons  had  already  thought  of  amputation, 
and  the  young  man  had  almost  consented  to  it,  when  we  recom- 
mended to  him  resolvents  and  the  application  of  a  compressive 
bandage  ;  an  amelioration  was  soon  apparent,  and  now  the  cure 
is  almost  complete ;  a  small  fistulous  point  upon  the  posterior 
surface  of  the  wrist  is  all  that  remains,  through  which  a  small 
drop  of  synovial  fluid  issues  daily. 

The  muscles  are  the  four  dorsal  interossei,  among  which  we 
distinguish  the  first  particularly,  both  on  account  of  its  volume 
and  because  the  radial  artery  traverses  it  posteriorly.  The 
others  fill  more  or  less  completely  the  interosseal  spaces,  and 


OF    THE    THORACIC    EXTREMITIES.  357 

their  posterior  extremity  also  gives  passage  to  an  artery :  it  is 
the  posterior  perforans,  which  goes  to  communicate  with  the  deep 
palmar  arch. 

v.  The  Arteries. 

The  radial  artery  merely  enters  this  region  in  order  to  pene- 
trate into  the  palmar  through  the  most  remote  part  of  the  first 
interosseal  space.  Its  relations  to  the  articulation  of  the  trape- 
zium with  the  first  metacarpal  bone  are  such,  that  it  is  almost  al- 
ways divided  in  the  extirpation  of  the  latter ;  but  it  would  be 
possible  to  avoid  it  by  carrying  the  edge  of  the  bistoury  close 
upon  the  bone  which  we  wish  to  remove.  The  other  arteries  of 
the  back  of  the  hand  originate  from  the  transverse  metacarpal, 
which  also  gives  off  the  dorsal  interossei  and  the  anterior  and 
posterior  perforating  branches.  The  posterior  branch  of  the 
ulnar  also  anastomoses  with  the  metacarpal  artery,  and  both  are 
applied  directly  upon  the  deep  sheet  of  the  aponeurosis.  It  is 
seldom  that  any  of  these  branches  are  so  large  as  to  exact  any 
precaution  during  surgical  operations. 

vi.  The  Veins. 

The  deep-seated  accompany  the  arterial  twigs  just  mentioned ; 
the  others,  or  the  subcutaneous  veins,  vary  in  number  and  are  very 
large.  Those  of  the  first  two  fingers  unite  in  order  to  form  the 
cephalic  of  the  thumb ;  those  of  the  last  three  are  generally  col- 
lected on  the  inner  side,  and  give  rise  to  the  salvatella.  These 
veins  run  in  the  superficial  cellular  layer,  and,  as  this  layer  sel- 
dom acquires  much  thickness  upon  the  back  of  the  hand,  we 
sometimes  perform  venesection  upon  the  metacarpus,  when  we 
experience  too  much  difficulty  at  the  fold  of  the  arm ;  in  which 
case  there  are  no  important  arteries  or  nerves  to  avoid,  and  the 
tendons  only  require  some  attention. 

vii.  The  Lymphatics. 

They  are  few  in  number,  and  soon  turn  over  the  borders  of 
the  hand,  in  order  to  become  continuous  with  those  of  the  palmar 


358  OF    THE    THORACIC    EXTREMITIES. 

aspect.     In  this  region,  as  well  as  in  the  preceding  and  the  wrist, 
lymphatic  glands  have  never  been  discovered. 

viii.  The  Nerves. 

Externally,  we  find  the  radial,  one  of  the  branches  of  which 
ramifies  upon  the  thumb  and  the  metacarpal  bone  which  sup- 
ports it,  whilst  the  other  subdivides  into  two  branches,  which  are 
distributed  to  the  index  and  middle  fingers.  Internally,  we  see 
the  posterior  branch  of  the  ulnar,  which  is  disposed  in  the  same 
manner  as  that  of  the  radial,  and  which  passes  to  the  last  two 
fingers.  These  nerves  penetrate  between  the  tendons  and  the 
two  aponeurotic  laminae :  they  seem  to  appertain  to  the  sensitive 
system. 

ix.  The  Skeleton. 

The  skeleton  of  this  region  comprises  all  the  bones  of  the 
metacarpus,  which  are  less  distant  from  each  other  than  in  the 
palmar  aspect,  on  account  of  their  being  broader  behind  than 
before,  and  they  also  present  a  convexity  instead  of  a  concavity. 
The  first  metacarpal  bone  being  shorter,  thicker,  more  moveable, 
and  more  thickly  covered  by  the  muscles,  than  all  the  others,  it 
follows  that  it  cannot  be  easily  fractured  ;  but  it  is  occasionally 
affected  with  caries,  necrosis,  or  other  diseases  which  render  its 
extirpation  necessary. 

A  great  many  methods  of  performing  this  operation  have  been 
advised ;  but  there  are  three  which  are  generally  adopted.  In 
the  first,  two  incisions  are  made,  commencing  from  the  point 
where  the  abductor  longus  pollicis  muscle  is  inserted,  and  carried 
one  behind  and  the  other  before,  uniting  them  on  the  inner  side 
of  the  root  of  the  thumb ;  after  which  the  bone  may  be  easily 
dislocated. 

In  the  second,  the  bistoury  is  at  first  thrust  from  without  in- 
wards, and  from  the  dorsal  towards  the  palmar  aspect,  across 
the  root  of  the  thenar  eminence,  in  order  to  form  a  flap  which  is 
prolonged  to  just  beyond  the  metacarpo-phalangeal  articulation, 
and  which  we  raise  in  order  to  penetrate  into  the  joint  by  its  ex- 
ternal part,  and  remove  the  bone  by  shaving  its  ulnar  surface. 


OP   THE    THORACIC    EXTREMITIES.  359 

111  the  third,  we  carry  the  bistoury,  its  cutting  edge  being  turned 
backwards,  from  the  middle  of  the  commissure  of  the  thumb  and 
index  finger  down  to  the  os  trapezium,  by  gliding  it  along  the  first 
metacarpal  bone  ;  we  then  disarticulate,  and  finish  the  operation 
by  forming  the  external  flap. 

In  certain  cases,  the  pathological  state  of  the  parts  will  doubt- 
less oblige  us  to  adopt  one  of  these  processes  in  preference  to 
the  others ;  but  where  the  surgeon  can  make  a  selection,  the  fol- 
lowing is  what  the  anatomical  arrangement  teaches  concerning 
the  respective  advantages  and  disadvantages  of  these  operatory 
methods :  In  the  first,  the  incisions  are  more  regular ;  it  is  easy  to 
avoid  the  radial  artery,  and  the  flaps  can  be  more  exactly  adapted 
to  each  other,  because  they  are  only  divided  upon  one  of  their 
borders ;  but  the  disarticulation  is  difficult  and  sometimes  very 
tedious,  because  we  cannot  sufficiently  incline  the  bone  in  adduc- 
tion in  order  to  luxate  it.  The  wound  is  necessarily  prolonged 
behind  the  joint,  the  flaps  are  quite  thin  in  this  direction,  and  the 
osseous  surfaces  cannot  always  be  properly  covered. 

In  the  second,  the  flap  is  more  speedily  formed ;  wre  enter 
more  easily  into  the  joint ;  the  arteries  may  be  as  readily  avoided, 
and  the  articular  surfaces  will  be  better  covered ;  but  the  flap  is 
frequently  unequal,  and  it  is  not  always  possible  to  give  it  suffi- 
cient thickness. 

In  the  third,  we  obtain  almost  all  the  advantages  of  the  two 
others,  without  incurring  their  inconveniences.  In  fact,  this 
method  is  easy,  certain,  and  expeditious.  It  must  only  be  recol- 
lected, that  by  pushing  the  instrument  too  far  backwards  we 
would  cut  the  radial  artery,  and  by  its  penetrating  between  the 
os  trapezium  and  trapezoides  might  remove  the  former  with  the 
metacarpal  bone :  but  this  mistake,  which,  however,  would  be 
attended  with  only  slight  inconvenience,  will  not  be  committed, 
if  we  take  care  to  direct  the  edge  of  the  bistoury  obliquely  out- 
wards, in  order  to  cut  the  capsular  ligament,  when  it  arrives 
opposite  to  the  termination  of  the  abductor  longus  pollicis,  at  the 
same  time  that  we  endeavour  to  luxate  the  bone  inwards.  This 
process,  advised  by  M.  Lisfranc,  seems  to  us  to  merit  the 
preference. 

The  last  four  metacarpal  bones  being  longer  and  more  im- 
moveable  than  the  first,  it  follows  that  they  may  be  occasionally 


360  OF    THE    THORACfC1    EXTREMITIES. 

fractured,  especially  by  direct  violence.  For  example,  when  the 
palmar  surface  is  laid  flat  upon  a  solid  plane,  if  a  foreign  body 
produces  forcible  compression  upon  it,  it  will  tend  to  efface  their 
natural  curvature,  and  may  break  them  in  their  middle  portion. 
Fractures  from  an  indirect  cause,  although  rare,  are  not  impos- 
sible. We  have  seen  a  water-carrier,  in  whom  the  third  meta- 
carpal  bone  was  broken  from  being  drawn  forcibly  by  the  index 
and  middle  fingers  by  a  cart- man. 

All  of  these  bones  may  be  amputated  in  their  continuity, 
xvhen  their  head  is  disorganized,  or  even  for  a  simple  disease  of 
the  finger,  when  we  wish  to  remove  the  annoying  thickness  of 
this  head. 

When  we  perform  this  operation  we  should  always  penetrate 
through  the  hand  from  the  dorsal  towards  the  palmar  surface : 
in  the  first  place,  because  on  the  dorsum  the  bones  are  easily 
felt  through  the  skin ;  and,  in  the  next  place,  because,  as  they 
are  broader  in  this  direction  than  anteriorly,  we  are  more  certain 
of  making  the  two  incisions  depart  from  the  same  point,  and  of 
uniting  them  upon  the  anterior  surface,  so  as  to  have  only  a  sin- 
gle division,  susceptible  of  cicatrizing  by  the  first  intention. 

Although  it  might  be  possible  to  remove  the  last  four  bones  of 
the  metacarpus  at  their  posterior  articulation,  it  would  never- 
theless be  difficult,  especially  with  regard  to  the  two  in  the  mid- 
dle, which  are  more  compactly  wedged  between  the  two  others. 
If  we  wished  to  amputate  that  which  supports  the  index  finger 
in  this  manner,  we  should  recollect  that  its  posterior  extremity 
receives  two  tendons,  and  that  its  articulatory  surface  is  slightly 
oblique  outwards ;  which  would  oblige  us  to  carry  the  knife  be- 
tween the  indicator  and  middle  finger. 

With  respect  to  the  fifth,  the  operation  is  not  much  more  diffi- 
cult than  for  the  first,  and  the  same  methods  have  been  applied 
to  it ;  as  the  fourth  also  rests  upon  the  anterior  face  of  the  os 
unciforme,  by  adopting  the  third  process  recommended  for 
the  thumb,  we  need  not  fear  making  the  same  mistake  relatively 
to  the  bones  of  the  carpus.  This  method  also  appears  to  us  to 
be  preferable,  unless  under  some  peculiar  circumstances.  By 
following  it,  it  will  always  be  easy  to  have  a  flap  of  suitable 
thickness,  provided  we  take  care,  the  point  of  the  bistoury  being 
held  upwards  and  its  cutting  edge  backwards,  to  incline  the  han- 


OP   THE   THORACIC    EXTREMITIES.  361 

die  of  this  instrument  towards  the  thumb,  in  order  that  the  an- 
terior incision  may  go  to  terminate  upon  the  origin  of  the  median 
line  of  the  palm  of  the  hand,  whilst  the  dorsal  incision  tends  to 
prolong  itself  towards  the  head  of  the  ulna.  In  this  manner,  the 
whole  of  the  hypothenar  eminence  will  be  preserved,  and  the 
point  of  the  bistoury  will  easily  penetrate  between  the  articular 
surfaces,  which  are  slightly  inclined  inwards  and  backwards. 
M.  Lisfranc  here  recommends  a  process  which  is  the  same,  in 
the  main,  with  that  which  we  pointed  out  in  the  second  place 
for  the  disarticulation  of  the  rnetacarpal  bone  of  the  thumb,  but 
which,  upon  the  dead  body,  has  always  appeared  to  us  more 
difficult  and  more  complicated  than  the  preceding.  We  think 
that  it  should  only  be  resorted  to  in  those  cases  in  which  we  have 
decided  upon  removing  the  metacarpal  bone  without  taking 
away  the  finger  which  it  supports,  as  has  once  been  successfully 
done  by  M.  Roux.  Finally,  whatsoever  method  the  surgeon 
may  adopt,  the  articulation  will  always  be  easily  recognised 
from  the  surface,  by  carrying  the  extremity  of  the  finger  along 
the  internal  posterior  border  of  the  bone  which  we  wish  to  ex- 
tirpate, when  the  first  prominence  which  he  meets  with  behind 
will  be  that  which  results  from  the  union  of  its  posterior  head  with 
the  os  unciforme.  It  may  be  observed,  before  abandoning  this 
point,  that,  by  following  the  advice  given  by  M .  Lisfranc  for  the 
amputation  of  the  fifth  metacarpal  bone  at  the  joint,  the  two 
arterial  palmar  arches  might  be  avoided,  whilst,  by  the  other 
methods,  they  would  almost  to  a  certainty  be  divided ;  but  as 
the  application  of  the  ligatures  will  not  present  any  peculiar  diffi- 
culties, we  think  that  it  will  have  little  or  no  effect  over  the  con- 
sequences of  the  operation,  and  therefore  ought  not  to  be  brought 
into  comparison  with  the  inconveniences  which  would  result 
from  the  multiplicity  of  incisions  required  by  the  former. 

The  arrangement  of  the  different  layers  of  the  back  of  the 
hand  is  so  simple,  that  it  is  almost  useless  to  describe  it  anew. 
However,  we  find,  1st,  the  skin;  2d,  the  cellular  layers  and 
veins ;  3d,  an  aponeurotic  lamina  and  some  nervous  filaments ; 
4th,  the  extensor  tendons,  the  nervous  branches  of  the  radial 
and  ulnar,  the  synovial  envelope;  5th,  a  second  fibrous  sheet, 
and  the  arteries ;  6th.  and  lastly,  the  bones  and  interossei  muscles. 

46 


36:2  OF    THE  -.THORACIC    EXTREMITIES'. 


ART.    VII.    OF    THE    FINGERS. 

Placed  parallel  to  one  another,  conical  and  more  slender  in 
children  and  females,  cylindrical  in  most  men,  all  the  fingers  are 
far  from  having  the  same  length.  The  medius  is  the  longest  of 
all ;  the  index  and  ring  fingers  usually  terminate  upon  the  same 
line,  although  in  reality  the  indicator  is  the  shortest,  because  its 
metacarpal  bone  is  the  longest ;  the  little  finger  terminates  on  a 
level  with  the  last  articulation  of  the  ring  finger,  and  the  thumb  at 
some  lines  behind  the  first  phalangeal  articulation  of  the  indica- 
tor. The  phalangeal  articulation  of  the  thumb  is  exactly  upon 
the  same  line  as  the  metacarpo-phalangeal  articulation  of  the  in- 
dicator, which  is  one  of  the  most  important  circumstances  to  be 
noticed,  as  it  may  assist  us  in  our  endeavours  to  penetrate  into 
these  articulations. 

Sect.  1.  Palmar  Region  of  the  Fingers. "" 

Upon  this  surface  the  fingers  present  a  considerable  number 
of  furrows,  with  which  it  is  useful  to  be  well  acquainted :  there 
is  one  only  before  each  of  the  last  phalangeal  articulations,  and. 
by  incising  perpendicularly  upon  it,  we  fall  about  a  line  behind 
the  joint.  There  are  several,  but  two  in  particular,  before  the 
middle  articulations.  Of  these,  the  posterior  is  the  most  con- 
stant ;  it  is  this  which  corresponds  to  the  joint  and  which  would, 
if  incised  upon,  lead  not  more  than  half  a  line  behind  it.  A  sim- 
ilar furrow  is  observed  at  the  union  of  the  palmar  portion  of  the 
hand  with  the  fingers ;  but  this  furrow  does  not  bear  the  same 
relations  to  the  articulations  as  the  preceding.  It  is  nearly  an 
inch  in  the  anterior  region  of  the  hand  that  the  metacarpo-pha- 
langeal union  of  the  fingers  is  met  with ;  to  this,  however,  the 
thumb  forms  an  exception,  for,  before  its  corresponding  articula- 
tion, we  may  observe  a  furrow,  which  is  disposed  as  in  the  mid- 
die  joints.  We  would,  moreover,  be  sure  to  fall  upon  the  meta- 
carpo-phalangeal articulation  of  the  thumb,  by  prolonging  upon 
its  base,  when  it  is  in  forced  abduction,  a  line  parallel  to  the  di 
rcctidn  of  the  index  finger. 

Between  these  different  furrows,  we  also  observe  some  wrin- 


OF    THE    THORACIC    EXTREMITIES.  303 

kles,  which  are   occasioned  by  the  plication  of  the  skin,   and 
which  are  parallel  to  the  direction  of  the  fingers. 

CONSTITUENT   PARTP. 

i.  The  Skin. 

This  membrane  is  of  a  dingy  colour ;  it  is  polished,  firm,  very 
thick,  smooth,  dense  and  compact.  It  has  not  yet  been  ascer- 
tained whether  it  possesses  sebaceous  follicles :  but  as  we  have 
acquired  the  conviction  that,  upon  the  other  parts  of  the  body, 
variolous  pustules  generally  have  their  seat  in  these  organs,*  and 
as  small-pox  pustules  are  developed  upon  the  fore  part  of  the 
fingers,  we  are  induced  to  believe  that  these  follicles  really  ex- 
ist in  it.  This  membrane  is  covered  with  an  innumerable  quan- 
tity of  papillary  lines,  arranged  in  various  directions,  but  which, 
upon  the  pulp,  generally  take  the  form  of  as  many  small  ellipses. 

n.  The  Subcutaneous  Layer. 

Upon  the  anterior  part  of  the  body  of  each  phalanx,  this  lay- 
er forms  a  very  remarkable  elastic  cushion,  the  thickness  of 
which  varies  in  different  subjects,  but  never  exceeds  certain  and 
even  somewhat  restricted  limits.  This  cushion  is  always 
thickest  upon  the  last  phalanx  and  passes  a  few  lines  beyond  it, 
forming  the  pulp  of  the  fingers ;  it  consists  of  fibro-cellular  fila- 
ments which  seem  to  be  detached  from  the  skin  in  order  to  inter- 
sect each  other  a  great  number  of  times,  and  thus  form  an  in- 
finite number  of  small  compartments,  in  which  adipose  vesicles 
are  imprisoned:  these  vesicles  are  small,  never  entirely  disap- 
pear, nor  become  so  large  as  to  deform  the  fingers.  When  they 
partially  collapse  in  thin  persons,  the  fingers  are  flattened  and 
their  articulations  appear  more  prominent ;  if,  on  the  contrary, 
they  are  distended,  the  fingers  become  rounded,  and  the  articu- 
lar furrows  deeper.  It  is  to  the  mixture  of  the  adipo-cellular 
vesicles  with  the  fibrous  filaments,  that  this  layer  owes  its  elasti- 
city, and  its  slight  extensibility.  It  is  intimately  united  with  the 

*  Voyez  Archives  gtntrdes  de  Mfrlecine.    Cahier  de  Juillet,  1825. 


364  OF    THE    THORACIC    EXTREMITIES. 

skin  and  fibrous  sheaths  of  the  tendons ;  all  the  nerves  and  ves- 
sels pass  through  and  are  even  distributed  to  it.  Before  the  ar- 
ticulations, the  fibrous  tissue  exists  alone,  and  connects  the  skin 
very  firmly  to  the  tendinous  sheaths ;  at  the  free  extremity  of 
the  fingers,  the  pulpy  substance  is  attached  directly  to  the  bone ; 
behind  the  last  transverse  grooves,  it  forms  the  anterior  elastic 
part  of  the  hollow  of  the  hand. 

It  follows  from  this  anatomical  disposition,  that  acute  inflam- 
mations must  be  easily  developed  in  this  layer,  since  it  contains 
some  cellular  tissue  and  numerous  vessels ;  that  these  inflamma- 
tions must  be  productive  of  very  acute  pain,  on  account  of  the 
density  of  the  tissue,  the  nerves  which  ramify  in  it,  and  the  resist- 
ance which  the  cutaneous  layer  must  oppose   to  the  tumefaction. 
Let  us  suppose,  for    instance,  that  a    needle    had  penetrated 
through  the  skin,  if  the  cellulo-adipose  tissue  inflames,  the  ele- 
ments, which  then  have  a  tendency  to  swell,  will  be  squeezed  be- 
tween the  two  articulations,  on  the  one  part,  and  between  the 
fibrous  sheath  and  the  skin,  on  the  other ;  they  will  thus  be,  as  it 
were,  strangulated,  and  will  be  more  firmly  compressed  in  pro- 
portion to  the  violence  of  the  inflammation ;  therefore,  it  is  well 
known  that,  in  order  to  remove  the  very  severe  pain  arising  from 
whitlow,  the  best  plan  is  to  make  deep  incisions  upon  the  palmar 
aspect  of  the  inflamed  finger.     When  the  inflammation  is  fur- 
ther  advanced,  and  pus  is  secreted,  the   species  of  sac  into 
which  the  fluid  will  be  forced  to  collect,  meeting  with  extreme 
resistance  on  all  sides,  on  account  of  the  thickness  of  the  skin, 
we  conceive  that  the  inflammation  will  extend  back  into  the  rest 
of  the  finger,  into  the  hand  and  even  the  fore-arm,  and  hence  all 
the  dangers  of  not  making  free  incisions  into  the  part  in  the  com- 
mencement of  the  disease.     If  it  is  too  true  that  the   whitlow 
which  has  its  seat  in  this  layer  is  a  serious  disease,  we  must  take 
care  and  not  mistake  it  for  that  form  of  onychia  which  is  called 
whitlow  of  the  first  species,  and  which  is  only  a  simple  inflamma- 
tion of  the  corpus  mucosum  of  the  skin.     In  fact,  the  latter  is 
never  very  painful,  and  only  deserves  attention  on  account  of  the 
constant  tendency  which  the  pus  has  to  detach  the  epidermis  ex- 
tensively, and  especially  around  the  nail ;  a  circumstance  which 
is  owing  to  the  great  thickness  of  the  cuticle  upon  the  fingers, 
and  which  exacts,  if  we  wish  to  stop  the  disease,  cm  early  remo- 


OF    THE    THORACIC    EXTREMITIES.  3G5 

'val  of  the  epidermis  thus  detached,  in  order  to  expose  the  whole 
of  the  diseased  surface. 

in.  The  Tendinous  Sheaths. 

These  sheaths  here  supply  the  place  of  the  palmar  aponeu- 
rosis,  and  are,  if  I  may  so  say,  only  a  modification  of  it.  The 
terminating  bandelets  of  the  latter,  are,  in  fact,  evidently  contin- 
uous with  their  longitudinal  fibres,  and  the  small  arcs  of  a  circle 
which  form  the  greater  part  of  the  sheath,  and  seem  to  be  merely 
the  continuation  of  the  transverse  fibres  of  the  aponeurosis. 
These  canals  are  completed,  posteriorly,  by  the  anterior  surface  of 
the  phalanges ;  their  transverse  section  has  the  form  of  an  ellipse, 
the  small  diameter  of  which  is  shorter  upon  the  articulations 
than  before  the  bodies  of  the  phalanges ;  their  anterior  or  fi- 
brous half  is  principally  formed  of  transverse  curves;  of 
very  strong  and  very  close  fibres  forming  a  very  thick  layer,  the , 
borders  of  which  are  inserted  into  the  sides  of  the  osseous  part. 
This  lamina  is  thinner  before  the  articulations,  especially  the 
middle  one,  than  in  their  intervals:  we  not  unfrequently  see 
small  spaces  between  their  fibres,  which  make  a  communication 
between  the  interior  of  the  sheath  and  the  preceding  layer,  and 
through  which  small  fatty  bodies,  or  processes  of  the  synovial 
membrane  of  the  tenjdons,  penetrate  from  one  to  the  other ;  it  is 
also  through  these  apertures  that  the  inflammations  mentioned 
above,  are  transmitted  to  the  serous  tunic  of  the  sheath,  and  that 
the  latter  may  escape  when  it  is  inflamed,  so  as  to  become  stran- 
gulated, and  thereby  occasion  extremely  acute  pains.  At  least, 
it  is  in  this  manner  that  some  persons  account  for  those  violent 
sufferings  which  certain  patients  experience  who  are  afflicted 
with  whitlow  of  the  third  species,  and  which  is  supposed  to  have 
its  seat  even  in  the  tendinous  theca.  When  these  thccae  have 
passed  beyond  the  third  articulation,  their  tissue  becomes  rare- 
fied, and  they  are  blended  with  the  pulp  and  periosteum :  their 
interior  is  lined  by  a  perfect  synovial  membrane,  which  does  not 
communicate  with  that  of  the  articulations.  When  it  arrives  at 
the  palm  of  the  hand,  this  membrane  gradually  disappears  in  the 
fibro-cellular  tissue  which  envelopes  the  flexor  tendons,  or  rather 
it  forms  a  species  of  cul-dr-sctc  upon  the  fore-part  of  the  trans- 


366  OF    THE    THORACIC    EXTREMITIES. 

verse  metacarpal  ligament,  and  thus  constitutes  a  small  elongated 
pouch  which  has  no  opening,  the  functions  as  well  as  the  diseases 
of  which,  are,  to  a  certain  degree,  independent  of  those  of  the 
other  organs  of  the  same  nature.  It  is  proper  to  remark  that, 
upon  the  fore  part  of  all  the  articulations,  and  especially  of  those 
•of  the  metacarpus  with  the  phalanges,  these  sheaths  are  altogeth- 
er fibrous ;  which  is  owing  to  the  transverse  ligament  here  form* 
ing  their  posterior  part,  covering  entirely  the  articular  surface. 

iv.  The  Tendons. 

Each  theca  includes  two  tendons,  except  that  of  the  thumb, 
which  contains  only  one.  These  cords  are  so  disposed  that  the 
tendon  of  the  sublimis  muscle,  which  is  at  first  applied  upon  the 
other,  gradually  splits  into  two  bandelets,  which  diverge  in  order 
to  give  passage  to  that  of  the  profundus :  whence  it  follows  that 
previous  to  this  division,  the  first  is  concave  upon  its  deep  sur- 
face, whilst  afterwards,  it  is  its  superficial  surface  which  presents 
a  gutter.  The  two  bandelets  then  turn  and  approach  each  other 
below,  and  are  inserted  into  the  anterior  and  lateral  parts  of 
the  second  phalanx,  blending  themselves  with  the  periosteum 
and  the  fibrous  sheath.  The  tendon  of  the  profundus  muscle, 
on  the  contrary,  terminates  upon  the  anterior  surface  of  the  last 
phalanx,  previous  to  which,  however,  it  detaches  a  flat  fibrous 
plate  of  greater  or  less  strength,  which  is  inserted  into  the  first 
phalanx,  but  which  does  not  interfere  with  its  free  motion.  This 
process,  called  falciforme  by  some  anatomists,  may  explain  how 
it  is  that  some  persons  are  able  to  flex  the  first  phalanx  with  facil- 
ity, after  the  last  two  have  been  amputated,  even  when  the  ends 
of  the  tendons  have  not  been  blended  by  the  effect  of  inflamma- 
tion, with  the  flap  which  covers  the  extremity  of  the  stump.  Sur- 
geons who  have  advised  amputation  at  the  metacarpo-phalan- 
geal  joint,  when  the  disease  would  have  permitted  the  opera- 
tion in  the  middle  articulation  of  the  finger,  were,  without  doubt, 
ignorant  of  this  anatomical  peculiarity,  when  they  advanced  that 
by  allowing  the  first  phalanx  to  remain  it  would  only  be  in  the 
way,  since  it  must  necessarily  remain  immoveable.  And  it  is 
probably  for  the  same  reason  that  others  have  advised  making 
several  deep  incisions  upon  the  palmar  surface  of  this  phalanx. 


OF  THE  THORACIC  EXTREMITIES.  367 

with  the  view  of  producing  adhesion  of  the  tendon  to  the 
surrounding  parts,  previous  to  amputating  either  of  the  other 
phalanges. 

The  thumb  has  no  flexor  sublimis  tendon,  whence  it  follows 
that  the  movements  of  its  first  phalanx  are  more  limited  than  those 
of  the  other  fingers.  Finally,  all  these  tendons  are  of  a  very 
dense  texture ;  their  fibres,  which  are  mostly  parallel,  are  very 
firmly  compacted  together ;  they  are  covered  by  the  synovial 
membrane  which  lines  their  sheath :  they  are  white,  smooth,  and 
almost  inert:  therefore,  when  they  remain  for  some  time  in 
contact  with  the  air,  they  slough  and  become  foreign  bodies.  It 
is  the  same  when  the  interior  of  their  sheath  suppurates,  or  at 
least  they  then  become  agglutinated  to  the  other  tissues,  and  the 
fingers  remain  immoveable. 

v.  The  Arteries. 

Each  finger  has  two  principal  arteries,  which  are  called  col- 
lateral, and  are  distributed  in  the  following  manner :  When  the 
most  considerable  trunks  of  the  superficial  palmar  arch  arrive 
opposite  to  the  interval  which  separates  the  heads  of  the  meta- 
carpal  bones,  each  of  them  bifurcates,  and  the  two  branches  of 
this  bifurcation  immediately  pass  upon  the  sides  of  the  two  corres- 
ponding fingers ;  they  then  apply  themselves  upon  the  sides  of 
the  tendinous  sheaths,  which  they  are  almost  in  immediate  contact 
with,  although  enveloped  in  the  superficial  layer ;  near  the  free 
extremity  of  the  finger,  they  turn  towards  each  other  and  anasto- 
mose, forming  a  loop  or  an  arch  in  the  digital  pulp.  In  their 
course,  these  branches  give  off  several  twigs  to  the  cellulo- 
adipose  layer,  which  are  entirely  distributed  to  this  membrane  ; 
they  are  very  large  in  proportion  to  the  organs  which  receive 
them,  and  it  is  well  known  that  the  arterial  system  abounds  in 
the  fingers.  It  is  not  necessary,  however,  to  secure  them  in 
amputations,  for  compression  is  generally  sufficient  to  stop  their 
bleeding.  They  are  always  situated  behind  the  collateral  nerves, 
arid  in  such  a  manner  that  a  transverse  incision  may  be  made 
upon  the  palmar  aspect  of  the  finger  down  to  the  theca,  without 
wounding  them :  it  also  follows  that  these  vessels  will  not  be 
divided  except  from  incisions  made  upon  the  sides  of  the  fin 


368  OF   THE    THORACIC   EXTREMITIES. 

gers:  finally,  when  we  amputate  at  the  metacarpo-phalangeal 
joint,  two  ligatures  only  will  be  necessary,  whether  the  division 
of  the  tissues  has  comprised  the  arterial  trunk  itself  previous  to 
its  bifurcation,  or  only  one  of  the  arteries  on  each  side. 

Some  small  arteries,  the  terminating  twigs  from  the  branches 
furnished  by  the  deep  palmar  arch,  are  also  distributed  to  the 
palmar  face  of  the  fingers  ;  but  they  are  only  important  as  they 
concern  the  nutrition  of  the  organs. 

vi.  The  Veins'. 

They  are  as  numerous  as  the  arteries ;  the  superficial  run  in 
the  subcutaneous  layer,  are  of  considerable  size,  and  accompany 
the  collateral  arteries ;  the  others  are  smaller,  scarcely  distinct, 
they  follow  the  arterial  ramuscules  of  the  deep  palmar  arch,  and 
form  the  roots  of  the  radial  vein,  collateral  to  the  artery  of 
this  name. 

vir.  The  Lymphatics. 

One  or  two  of  these  vessels  are  situated  upon  each  side  of  the 
fingers ;  they  accompany  the  arteries  or  blood  vessels  in  general. 
and  are  of  no  great  importance  in  surgery. 

viii.  The  Nerves. 

They  are  distributed  exactly  in  the  same  manner  as  the  collat- 
eral arteries,  before  which  they  are  situated ;  the  palmar  nerves 
of  the  fingers  are  all  derived  from  the  median  and  ulnar.  The 
former  supplies  the  thumb,  index,  and  middle  fingers,  and  one  of 
its  branches  also  follows  the  radial  border  of  the  ring  finger,  at 
the  extremity  of  which  it  anastomoses,  in  the  form  of  an  inverted 
arch,  with  the  ulnar,  which  besides  supplies  the  little  finger.  As 
these  extremely  large  branches  are  placed  before  the  vessels, 
they  may  be  wounded  without  the  arteries  being  touched ;  they 
ramify  and  are  entirely  lost  in  the  subcutaneous  elastic  layer  and 
skin ;  which  leads  to  the  belief  that  all  these  nerves  appertain  to 
the  sensitive  system :  therefore  the  fingers  are  endowed  with  a 
remarkable  sensibility,  which  constitutes  the  most  wonderful 


OP  THE    THORACIC    EXTREMITIES.  369 

of  their  functions.  From  the  great  quantity  of  nervous  filaments, 
distributed  throughout  the  first  two  layers  of  the  palmar  aspect 
of  the  fingers,  we  may  also  account  for  the  agonizing  pains  before 
spoken  of. 

ix.  The  Skeleton. 

We  have  only  to  consider  here  the  anterior  surface  of  the  pha- 
langes and  of  their  articulations.  All  these  small  bones  are 
slightly  concave  transversely  and  longitudinally,  which  enables  us, 
in  amputations,  to  cut  a  flap  of  sufficient  breadth  and  thickness 
upon  the  palmar  aspect  of  the  fingers.  All  of  these  articula- 
tions bulge  out  a  little ;  the  last  two  transversely,  the  first  in  a 
spherical  manner :  whence  it  follows,  that,  if  we  amputate  the 
first  or  second  phalanx,  in  commencing  by  cutting  a  flap  from 
within  outwards  upon  the  palmar  surface,  as  recommended  by 
M.  Lisfranc,  the  surgeon  should  be  careful  to  stop  the  base  of 
this  flap  on  a  level  with  the  furrow  which  we  have  noticed  upon 
the  surface,  and  not  carry  the  bistoury  backwards  farther  than 
the  middle  of  the  first  eminence  which  he  will  meet  with  in  as- 
cending from  the  free  extremity  towards  the  root  of  the  organ  ; 
that,  in  another  process,  advised  by  the  same  author,  and  which 
consists  in  falling  directly  upon  the  joint,  we  should  also  take 
great  care  how  we  carry  the  instrument  behind  this  eminence, 
because  the  species  of  neck  upon  which  it  would  then  strike,  will 
deceive  the  surgeon,  and  he  may  be  embarrassed  for  a  long  time 
before  he  discovers  his  error.  The  fold  of  the  skin  is  also  a  sure 
guide  to  prevent  making  this  mistake ;  but  it  must  not  be  for- 
gotten, that  the  only  furrow  which  we  see  behind  the  digital  pulp, 
will  conduct  directly  upon  the  neck  in  question,  if  we  do  not  cut 
about  a  line  before  it,  since  the  articulation  is  actually  a  little 
anterior  to  it ;  that,  as  it  regards  the  union  of  the  first  two  pha- 
langes, it  is  always  the  most  remote  of  those  grooves  which  are 
found  before  the  joint,  which  must  be  recollected,  and  that  this 
groove  is  seldom  more  than  half  a  line  posterior  or  anterior  to 
the  articulation. 

With  respect  to  the  posterior  articulation,  we  would  find  it  by 
following  a  slightly  curved  line  with  an  anterior  convexity,  the 
extremities  of  which  would  fall  behind  the  index  and  little  fin- 

47 


370  OF    THE    THORACIC    EXTREMITIES, 

gers,  about  three  lines  before  the  transverse  groove  of  the  hand. 
But,  as  we  do  not  penetrate  into  this  joint  by  the  palmar  surface, 
we  will  defer  the  further  consideration  of  it  until  we  come  to 
treat  of  the  dorsal  portion. 

Sect.  2.  Dorsal  Region  of  the  Fingers. 

This  aspect  is  longer  than  the  anterior,  because  in  the  latter 
the  palm  of  the  hand  is  prolonged,  as  we  have  seen,  upon  the 
posterior  third  of  the  first  phalanges.  Its  surface  presents,  when 
the  fingers  are  extended*  the  termination  of  the  three  grooves 
mentioned  when  describing  the  back  of  the  hand;  grooves 
which,  by  uniting  the  dorsal  and  palmar  faces,  form  a  thin  and 
concave  border,  which  we  may  call  the  commissure  of  the  fingers. 
Between  these  grooves,  we  observe  the  reliefs  produced  by  the 
continuation  of  the  extensor  tendons.  During  flexion  there  exist 
three  strongly  marked  angular  eminences  for  each  finger,  which 
correspond  to  the  articulations,  but  in  such  a  manner  that  it  is 
always  the  anterior  phalanx  which  has  glided  over  the  posterior, 
and  the  head  of  the  latter  alone  projects  under  the  skin ;  a  cir- 
cumstance to  be  recollected  when  we  amputate.  In  all  posi- 
tions, but  more  especially  in  semi-flexion,  there  are  many  trans- 
verse wrinkles  observed  upon  the  posterior  digital  surface, 
scarcely  perceptible  upon  the  bodies  of  the  phalanges,  but  al- 
ways very  distinct  in  the  immediate  neighbourhood  of  the  joints, 
There  are  generally  three  of  these  furrows  upon  each  articula- 
tion :  one  before,  another  behind,  and  the  third  in  the  middle. 
The  last  is  generally  the  deepest,  and  it  is  about  two  lines  before 
it  that  the  incision  must  be  made,  if  we  cannot  discover  the  ante- 
rior, in  order  to  penetrate  into  the  joint.  It  is  necessary  to  note, 
however,  that  this  disposition  does  not  exist  with  respect  to  the 
metacarpo-phalangeal  articulations. 

CONSTITUENT    PARTS, 

i.  The  Skin. 

The  skin  is  uneven!  plicated,  and  supports  a  group  of  hairs,  in 
the  adult  man,  upon  the  bodies  of  the  first  two  phalanges ;  it  is 


OF    THE    THORACIC    EXTREMITIES.  371 

more  coloured,  supple,  and  extensible  than  that  of  the  palmar 
surface,  but  it  is  also  much  thinner,  less  dense  and  compact ;  ex- 
cept by  its  folds,  it  scarcely  differs  from  that  of  the  back  of  the 
hand ;  it  also  contains  some  distinct  sebaceous  follicles.  When 
it  comes  near  to  the  nail,  it  is,  in  the  first  place,  reflected  back 
upon  its  root,  to  the  extent  of  about  a  line  and  a  half  or  two 
lines,  and  in  this  manner  forms  for  it  a  species  of  matrix,  which 
we  should  not  fail  to  cut  perpendicularly  and  in  the  direction  of 
the  contour  of  this  horny  production,  when  we  wish  to  extirpate 
the  latter ;  indeed,  by  taking  this  precaution,  we  would  diminish 
the  excruciating  pains  which  this  little  operation  usually  produces. 
Next,  the  integuments  slide  under  the  borders  of  this  inert  plate, 
and  become  continuous,  under  its  free  edge,  with  the  skin  of  the 
pulp  of  the  fingers ;  its  texture  is  then  much  more  compact ;  the 
dermis  adheres  almost  directly  to  the  bone,  and  it  is  the  epidermis 
more  particularly  which  envelopes  the  root  of  the  horny  plate ; 
now,  as  it  is  between  these  two  laminae  that  the  pus  or  morbid 
fluids,  consequent  upon  onychia,  accumulate,  we  need  not  be 
surprised  that  the  nail  afterwards  drops  off. 

ii.  The  Subcutaneous  Layer. 

This  layer  is  merely  the  continuation  of  that  of  the  back  of 
the  hand,  and  is  also  entirely  different  from  that  of  the  palmar 
aspect.  In  the  point  under  consideration,  it  sometimes  contains 
fatty  cells  of  a  certain  volume  ;  upon  the  articulations,  its  laminae 
are  united,  condensed,  and  frequently  transformed  into  a  sort  of 
saccus  mucosus ;  as  they  approach  the  nail,  they  become  more 
dense,  and  are  blended  with  the  periosteum  and  skin.  The 
veins  and  nervous  filaments  run  between  them,  and  the  diseases 
which  are  developed  in  this  layer  are  attended  with  the  same 
phenomena  as  in  the  corresponding  aspect  of  the  hand,  of  the 
fore-arm,  etc. 

in.  The  Aponeurosis. 

There  is  none,  properly  speaking ;  this  layer  is  confounded 
with  the  tendon?. 


372  OF    THE    THORACIC    EXTREMITIES. 


iv.  The  Tendons. 

These  cords  are  somewhat  complicated:  when  they  have 
passed  beyond  the  metacarpo-phalangeal  articulation,  they  re- 
ceive upon  their  borders  the  tendons  of  the  lumbricales  and 
interossei  muscles,  which  may  thereby  become  flexors  of  the  first 
phalanx.  Behind  the  first  phalangeal  articulation,  the  extensor 
tendon  expands  and  even  separates  into  two  bands,  united  by  a 
thinner  membrane,  and  thus  passes  upon  the  second  phalanx. 
The  two  bands  then  approximate  and  afterwards  separate  anewr, 
in  order  to  cover  the  last  joint,  and  finally  terminate  near  the 
nail.  These  tendons  have  no  sheaths ;  but  the  membrane  which 
continues  their  margins  fixes  them  in  a  pretty  solid  manner  upon 
the  back  of  the  fingers,  so  that  they  cannot,  under  any  circum- 
stance, slip  to  one  side  or  the  other.  They  are  not  enveloped 
by  a  synovial  membrane,  but  they  rest  immediately  upon  those 
of  the  articulations  and  upon  the  body  of  the  bones ;  a  very 
supple  and  extensible  lamellated  cellular  tissue  enables  them  to 
slide  with  facility. 

v.  The  Arteries. 

These  arteries  are  very  delicate  and  almost  capillary ;  they  are 
derived  from  the  transverse  metacarpal,  the  interosseus  branches 
of  the  deep  palmar  arch,  and  the  collaterals.  Wounds,  there- 
fore, upon  the  back  of  the  fingers  do  not  occasion  troublesome 
hoBmorrhage. 

vi.  The  Veins. 

They  are  of  considerable  size ;  upon  the  dorsum  of  the  first 
phalanx  they  sometimes  form  a  species  of  plexus,  and  may  gen- 
erally be  perceived  through  the  skin.  In  short,  the^veins  are 
much  larger  here  than  those  upon  the  anterior  aspect,  and  pass 
to  the  salvatella  or  the  cephalic  of  the  thumb. 


OF    THE    THORACIC    EXTREMITIES.  373 


VH.  The  Lymphatics. 

They  form  the  root  of  the  lymphatics  of  the  back  of  the  hand, 
communicate  with  those  of  the  palmar  surface  of  the  fingers, 
and  are  not  more  important,  as  relates  to  surgery,  than  the 
latter. 

VHI.  The  Nerves. 

The  posterior  branch  of  the  ulnar  supplies  the  little  and  ring 
fingers,  and  also  the  ulnar  side  of  the  middle  finger ;  the  radial 
nerve  supplies  the  thumb  and  indicator,  and  generally  sends  a 
small  branch  to  the  middle  finger  also.  According  to  this  ar- 
rangement, we  perceive  that  a  wound  inflicted  upon  the  ulnar 
side  of  the  wrist  would  partially  paralyze  the  last  three  fingers, 
whilst  a  similar  injury  upon  the  radial  side  would  act  upon  the 
first  three  only.  However,  as  these  nerves,  as  well  as  the 
branches  of  the  median  upon  the  palmar  surface,  apparently  be- 
long to  sensation  alone,  it  would  be  interesting,  and  not  unimpor- 
tant, to  ascertain  if  it  would  be  possible  to  paralyze  the  fingers 
completely,  by  dividing  the  nerves  at  the  lower  part  of  the  fore- 
arm, without  touching  the  tendons. 

ix.  The  Skeleton. 

We  will  here  examine  the  phalanges  and  the  head  of  the  met- 
acarpal  bones,  or  rather  these  different  bones  and  their  articula- 
tions. The  shortness  of  the  former  and  their  great  mobility, 
render  their  fractures  very  rare,  and  almost  prevent  the  occur- 
rence of  these  accidents  unless  by  direct  causes.  With  respect 
to  luxations,  they  are  more  readily  produced  in  some  articulations 
than  in  others.  In  the  metacarpo-phalangeal  articulations,  for 
example,  they  are  less  frequent  in  the  three  middle  fingers  than 
in  the  first  and  last.  In  this  respect,  see  what  anatomy  teaches 
us :  anteriorly,  the  joint  is  firmly  secured  by  the  anterior  liga- 
ment, the  flexor  tendons  and  their  theca? ;  the  flattened  bands  of 
the  extensors  are  found  alone  behind  ;  the  lateral  parts  are  main- 
tained by  two  strong  ligaments,  and  strengthened  by  the  tendons 


374  OF    THE    THORACIC    EXTREMITIES. 

of  the  interossei  and  lumbricales.  On  the  other  hand,  the  head 
of  the  metacarpal  bones  is  so  much  inclined  forwards,  that  the 
phalanx  may  turn  upon  it  so  as  to  form  a  right  angle,  without  the 
articular  surfaces  thereby  losing  their  natural  relations :  the  luxa- 
tion, therefore,  will  be  so  much  the  more  difficult  in  this  direc- 
tion, as  the  fibrous  parts  oppose  an  extreme  resistance  to  the  dis- 
placing powers ;  and  also,  as  the  articular  surfaces  admit  of  very 
extensive  motion,  which  is,  besides,  checked  by  the  palm  of  the 
hand  itself,  before  the  osseous  surfaces  can  abandon  each  other. 
On  the  dorsal  side,  on  the  contrary,  no  ligaments,  no  fibrous 
sheaths ;  a  single  tendon,  thin  and  affording  but  little  resistance, 
because  its  adhesion  to  the  joint  is  very  slight ;  articular  surfaces, 
which  tend  to  be  displaced  whenever  the  movement  of  exten- 
sion passes  a  little  beyond  its  natural  limits,  and  nothing  upon  the 
back  of  the  fingers  to  check  this  movement ;  these  are  so  many 
circumstances  favorable  to  dislocations  backwards.  Although 
this  is  an  arthrodial  articulation,  its  lateral  displacements  are, 
nevertheless,  very  rare  ;  in  the  first  place,  on  account  of  the 
strength  of  the  lateral  ligaments ;  and  in  the  second,  because  the 
movements  of  abduction  and  adduction  are  naturally  very  lim- 
ited. With  respect  to  the  little  finger,  the  luxation  must  be  more 
common  forwards,  on  account  of  the  adductor  and  flexor  brevis 
muscles,  which  are  inserted  into  the  first  phalanx.  It  would 
also  seem,  that  in  the  thumb  it  would  be  still  more  readily  pro- 
duced, on  account  of  the  muscles  of  this  finger,  which  are 
stronger  and  more  numerous ;  but  this  advantageous  disposition 
is  counterbalanced  by  the  presence  of  the  ossa  sesamoidea, 
which  sometimes  very  considerably  augment  the  extent  of  the 
articular  surface  of  the  first  metacarpal  bone  ;  it  should  also  be 
noted,  that  these  supernumerary  bones  partially  convert  the  ar- 
ticulation under  consideration  into  a  ginglymus.  Moreover, 
when  this  displacement  has  once  occurred,  the  muscles  must 
afford  great  opposition  to  the  reduction.  Prof.  Boyer,  who  does 
not  appear  to  have  met  with  this  species  of  luxation,  thinks,  how- 
ever, that  if  it  existed  it  might  be  easily  reduced ;  whilst  he  says, 
that  he  himself,  as  well  as  Chopart  and  Desault,  had  failed  in  re- 
ducing certain  dorsal  luxations  some  days  after  the  accident.  We 
have  only  once  seen  the  first  phalanx  of  the  thumb  pass  before 
the  first  metacarpal  bone  ;  but  this  case  is  in  direct  opposition  to 


OF    THE    THORACIC    EXTREMITIES.  375 

the  opinion  of  the  celebrated  surgeon  just  cited.  The  subject 
was  a  female,  aged  45  years;  the  luxation  had  existed  three 
days ;  there  was  no  inflammation.  We  endeavoured  to  reduce 
it,  but  all  our  efforts  were  unavailing.  M.  Prof.  Bougon  also 
made  vain  attempts  on  the  day  following ;  and  four  days  after- 
wards, Prof.  Roux,  notwithstanding  his  well-known  skill  and  dex- 
terity, was  equally  unsuccessful. 

The  fibrous  elements  which  surround  the  phalangeal  articula- 
tions, are  absolutely  similar  to  those  which  we  have  seen  in  the 
preceding;  but  the  articular  surfaces  differ  from  them,  inasmuch 
as  they  form  a  complete  ginglymus ;  lateral  luxations  of  them, 
therefore,  must  be  still  more  difficult.  In  order  that  these  dis- 
placements may  take  place  forwards,  they  must  overcome  the 
same  difficulties ;  the  condyles  of  the  first  phalanx  are  as  much 
rounded  anteriorly  as  the  head  of  the  metacarpal  bones,  and  the 
flexion  of  the  fingers  may  be  carried  still  farther :  it  is  posteri- 
orly, then,  that  the  luxation  is  most  likely  to  occur.  It  is  proper 
to  observe,  however,  that  the  condyles  of  the  second  phalanx  are 
not  so  much  inclined  upon  the  dorsal  surface  as  those  of  the  first ; 
whence  it  follows  that  the  last  phalanx  would  be  luxated  for- 
wards more  easily  than  the  bone  with  which  it  is  articulated : 
this  luxation,  on  the  contrary,  is  more  common  in  the  thumb, 
and  there  are  persons  who  can  produce  and  reduce  it  at  pleasure  ; 
which  can  only  depend  upon  the  laxity  of  the  ligaments  and  the 
particular  disposition  of  the  articular  facets  in  such  persons. 

In  relation  to  amputations,  the  skeleton  of  the  fingers  also  pre- 
sents some  remarkable  peculiarities :  thus  the  convex  form  of  the 
back  of  the  phalanges  will,  in  most  cases,  prevent  the  formation 
of  a  dorsal  flap  of  sufficient  breath  or  thickness,  even  if  the 
thickness  of  the  soft  parts  would  permit  it ;  it  is  for  this  reason 
that  the  English  recommend  making  a  circular  incision  through 
the  skin  three  or  four  lines  before  the  joint,  in  order  to  form 
afterwards  two  flaps,  by  making  two  other  incisions  upon  the 
borders  of  the  phalanx  ;  but  for  this  method,  as  well  as  the  cir- 
cular method  in  general  and  many  other  modifications,  those 
which  were  pointed  out  when  on  the  palmar  surface  are  advan- 
tageously substituted,  and  especially  that  which  consists  in 
making  a  semi-lunar  incision  through  the  skin  and  flexor  tendon 
upon  the  anterior  cutaneous  furrow  of  the  articulation,  or  two 


376  OF    THE    THORACIC    EXTREMITIES, 

lines  before  the  middle  fold  :  we  then  fall  exactly  into  the  joint  •, 
only,  in  order  to  traverse  it,  we  must  take  care  to  cut  the  two 
lateral  ligaments,  and  to  recollect  that  the  condyles  of  the  posterior 
phalanx  look  directly  forwards,  in  order  that  we  may  incline  the 
handle  of  the  instrument  less  backwards.  Besides,  as  the  articula- 
tion is  very  close,  and  as  the  extremity  of  the  phalanx  which  we 
wish  to  remove  makes  a  considerable  bulge,  it  will  be  necessary 
to  use  an  instrument  with  a  narrow  blade,  and  to  carry  the  edge  of 
it  sufficiently  forwards  in  order  to  be  able  to  place  it  horizontally 
and  form  the  flap,  by  shaving  the  palmar  aspect  of  this  bone. 

The  metacarpo-phalangeal  articulation  being  of  a  different 
kind,  the  steps  of  the  operation  are  no  longer  the  same  when  we 
amputate  the  first  phalanx.  After  having  made  a  flap  by  means 
of  a  semi-lunar  incision,  the  convexity  of  which  corresponds  to 
the  middle  of  the  commissure  of  the  fingers,  and  the  extremities 
of  which  fall  before  and  behind  the  articulation,  in  order  to  disco- 
ver the  latter,  it  is  sufficient,  as  M.  Lisfranc  has  very  correctly 
stated,  to  draw  the  edge  of  the  bistoury  backwards  along  the 
phalanx,  its  point  being  at  the  same  time  directed  upwards.  The 
first  prominence  which  we  then  meet  with  is  the  head  of  the  pha- 
lanx ;  the  articulation  will  always  be  found  some  lines  farther,  and 
in  order  to  traverse  it,  all  that  is  necessary  is  to  divide  the  liga- 
ments and  tendons  with  the  extremity  of  the  instrument  held 
transversely,  whilst  we  endeavour  to  luxate  the  bone  with  the 
other  hand.  Moreover,  it  is  always  easy  to  discover  this  articu- 
lation ;  the  prominence  which  the  metacarpal  heads  form  exter- 
nally, sufficiently  shews  the  place  which  it  occupies ;  and  if  the 
morbid  swelling  prevented  us  from  seeing  this  prominence,  we 
should  recollect  that  the  joint  is  always  eight  or  ten  lines  behind 
the  digital  commissure.  Finally,  as  all  the  metacarpal  joints  are 
upon  a  slightly  curved  line,  almost  regular,  at  least  with  respect  to 
the  last  four,  and  as  the  palm  of  the  hand  is  prolonged  upon  the 
palmar  surface  of  the  first  phalanges,  it  follows  that,  if  the  occa- 
sion should  require,  we  might  amputate  the  four  fingers  simulta- 
neously ;  that  is  to  say,  that  we  might  make  a  curved  incision, 
convex  anteriorly,  upon  the  fore-part  of  all  the  articulations, 
afterwards  penetrate  into  each  of  them  separately,  and  finish 
the- operation  with  a  knife,  forming  only  a  single  flap  for  all  the 
fingers,  at  the  expense  of  the  palmar  part  of  the  hand.  This  pro- 


OP    THE    CHEST.  877 

cess,  advised  by  M.  Lisfranc,  has  always  appeared  to  us  simple 
and  very  easy  upon  the  dead  body. 

After  the  amputation  of  a  single  finger  in  its  articulation  with 
the  hand,  the  head  of  the  metacarpal  bone  forms  a  projection 
which,  after  the  cure,  keeps  the  two  collateral  fingers  very  much 
separated  for  a  considerable  time.  Some  surgeons  have  supposed 
that  this  inconvenience  might  be  avoided  by  amputating  in  the  con- 
tinuity of  the  metacarpal  bone,  and  that  in  this  case  the  deformity 
would  be  less.  It  is  true  that  the  operation  is  easy ;  but  it  is  undoubt- 
tedly  much  more  painful  than  the  other ;  in  fact,  we  are  obliged  to 
divide  a  much  greater  thickness  of  the  tissues,  and  the  cicatrization 
will  not  always  be  so  prompt ;  besides,  the  volume  of  the  head 
gradually  diminishes,  by  the  gentle  pressure  which  the  surround- 
ing parts  constantly  exercise  upon  it,  and  the  roots  of  the  two 
fingers  become  at  length  much  more  approximated  than  we  would 
at  first  have  imagined. 


CHAPTER  IV. 

OF  THE  CHEST. 

The  Chest  forms  the  middle  cavity  of  the  body,  and  is  contin- 
uous, superiorly,  with  the  neck,  inferiorly  with  the  abdomen,  and 
serves  as  a  point  of  attachment  to  the  superior  extremities.  The 
figure  of  its  skeleton  is  that  of  a  truncated  cone  with  an  inferior 
base.  When  it  is  surrounded  by  its  soft  parts,  on  the  contrary, 
its  superior  part  is  broadest ;  in  this  direction  it  appears  as  if  flat- 
tened :  and  its  transverse  diameter,  from  shoulder  to  shoulder,  is 
greater  than  its  antero-posterior.  This  form  presents  gradations 
infinitely  varied,  according  to  age,  sex,  and  individuals.  Anato- 
mists having  for  a  long  time,  divided  the  skeleton  of  this  cavity 
into  four  regions,  and  as  this  division  can  be  pretty  exactly  traced 
upon  the  surface,  we  are  induced  to  follow  it,  with  the  exception, 
however,  of  pointing  out  slight  modifications  which  appear  to  us 
indispensable,  in  speaking  of  the  principal  sections. 

In  the  first  place  we  will  examine  the  thorax  properly  so  call- 
called,  or  the  containing  parts ;  in  the  second,  the  cavity  of  the 
thorax  and  the  contained  parts. 

48 


ART.  1.  01   THE  TJIORAX. 

Sect.  1.  Anterior  or  Sternal  Region. 

It  is  bounded,  superiorly,  by  the  infra-hyoideal  and  supra-clavi 
cular  regions  ;  inferiority,  by  a  curved  line  which  unites  the  epi- 
gastrium to  the  chest,  and  laterally,  by  the  two  clavi-coxal  lines 
which  separate  it  from  the  axillary  region  above,  and  from  the 
costal  region,  properly  so  called,  below.  The  surface  of  this 
region  presents,  in  the  middle  and  from  above  downwards,  tlit 
supra-sternal  notch,  much  deeper  in  emaciated  than  fat  persons  ; 
a  depression  which  corresponds  to  the  os  primi-sternal  (Beclard); 
an  eminence,  which  does  not  always  exist,  and  which  depends 
upon  the  more  or  less  angular  junction  of  the  primi  et  duo-ster- 
nales ;  a  second  depression,  more  constant  than  the  first,  of  which 
it  is  sometimes  the  continuation,  and  which  generally  increases  in 
depth  in  proportion  as  it  approximates  the  fore  part  of  the  xiphoid 
appendix,  upon  which  we  almost  always  observe  an  excavation, 
and  the  point  of  which  occasionally  forms  a  relief  under  the  skin  ; 
upon  the  sides,  the  prominences  produced  by  the  heads  of  the 
clavicles  ;  below,  in  thin  individuals,  a  series  of  hollows  and  ris- 
ings which  are  in  relation  with  the  intercostal  spaces  and  the  car- 
tilages which  circumscribe  them  ;  in  fat  persons,  on  the  contrary, 
we  remark  a  prominence,  elongated  parallel  to  the  axis  of  the 
bodv,  and  which  is  owing  to  the  muscles  and  the  cellulo-adipose 
tissue.  Childhood,  sex,  embonpoint  and  constitution  occasion 
numerous  modifications  in  these  different  features.  Thus,  in  the 
first  age,  this  region  is  generally  very  protuberant,  and  forms  a 
considerable  arch ;  there  is  no  relief  upon  the  sides.  In  women 
it  is  flatter  and  shorter ;  but  the  breasts  cause  the  median  groove 
to  appear  deeper,  and  the  clavicular  extremity  is  more  prominent ; 
in  some  adults,  the  sternal  region  projects  as  in  childhood,  and 
this  disposition,  which  frequently  coincides  with  rachitism,  induces- 
us  to  apprehend  phthisis  pulmonalis.  In  others,  on  the  contrary, 
it  is  more  depressed  than  in  the  well-formed  state,  as  is  observed 
especially  in  mechanics  who  labour  with  the  trunk  habitually 
curved  forwards,  and  which  they  make  use  of  as  a  point  of  sup 
port,  shoe-makers,  for  example ;  finally,  it  is  not  very  uncommon 


OP   THE    CHEST.  379 

to  meet  with  a  certain  degree  of  mobility  upon  the  median  line, 
and  some  inequalities  which  depend  upon  the  imperfect  or  irreg- 
ular union  of  the  different  pieces  of  the  sternum.  It  is  especially 
necessary  to  recollect  these  varieties,  when  it  is  required  to  deter- 
mine the  existence  of  fractures  or  tumours  which  frequently  man- 
ifest themselves  in  this  region. 

CONSTITUENT    PART?. 

i.  The  Skin. 

In  both  sexes,  it  is  much  thicker  in  the  middle  than  laterally  ; 
in  the  adult  man  it  is  shaded,  throughout  the  whole  extent  of  the 
median  excavation,  with  hairs,  the  roots  of  which  are  surrounded 
with  numerous  large  follicles  ;  therefore  the  lupia,  the  acne  punc- 
tata,  and  pustules  similar  to  those  which  we  so  frequently  observe 
upon  the  face,  often  have  their  seat  before  the  sternum,  whilst 
they  are  very  rare  upon  the  sides,  where  the  skin  does  not  pre- 
sent the  same  characters.  In  women,  all  things  else  being  equal, 
the  skin  is  more  delicate,  smooth  and  polished  and  especially  much 
whiter  as  it  extends  towards  the  breasts.  As  its  extensibility  is 
much  greater  externally  than  upon  the  median  line,  tumours 
which  form  beneath  it  more  readily  acquire  a  considerable  mag- 
nitude in  the  first  direction  than  in  the  second. 

ii.  The  Subcutaneous  Layer. 

In  emaciated  subjects  it  consists  of  a  lamellated  and  filament- 
ous cellular  tissue,  and  then  forms  a  membrane  of  considerable 
thickness  and  very  extensible  upon  the  muscles,  where  it  supplies 
the  place  of  the  aponeurosis ;  as  it  passes  upon  the  middle  por- 
tion it  becomes  more  dense,  as  it  were  fibrous,  and  is  blended 
with  the  sterno-costal  ligaments.  We  may  separate  from  it  a 
lamina  which  adheres  more  particularly  to  the  skin,  and  in  which 
the  adipose  vesicles  are  deposited.  This  latter  sheet  is  only  a 
continuation  of  the  superficial  layer  of  the  neck,  thoracic  extrem- 
ities, etc. ;  in  short,  it  is  only  a  portion  of  the  general  fascia  su- 
perficialis.  The  disposition  of  these  sheets  is  such,  that  exter- 
nally they  split  into  three  layers :  the  first  appertains  to  the  integ- 


380  OF    THE    CHEST. 

uments ;  the  second  is  applied  directly  upon  the  muscles,  and  the 
third  is  intermediate ;  but  upon  the  median  line  they  become 
blended  together,  and  never,  or  at  least  but  very  seldom,  contain 
fat ;  and  as  they  also  unite  the  bones  very  intimately  to  the  skin,  it 
follows  that  wounds  in  this  situation  are  very  difficult  to  unite  by 
the  first  intention,  and  that,  in  the  operations  which  we  perform 
upon  it,  it  is  necessary  to  preserve  as  much  of  the  integuments 
as  possible,  if  we  do  not  wish  to  lay  the  foundation  for  almost  in- 
terminable ulcers.  It  also  follows  that  in  infiltrations  and  obe- 
sity, the  sternum  appears  to  be  much  depressed.  Further,  this 
cellulo-adipose  tissue,  in  curving  under  the  inferior  margin  of  the 
pectoralis  major  muscle,  becomes  directly  continuous  with  that 
of  the  axilla,  and  thereby  favours  the  passage  of  morbid  fluids 
from  one  of  these  regions  to  the  other. 

in.  The  Aponeurosis. 

Laterally,  from  the  clavicle  to  just  below  the  pectoralis  major, 
it  consists  only  of  the  simple  cellular  lamina  already  mentioned, 
and  which  is  blended  before  the  sternum  with  the  periosteum  and 
the  preceding  layer.  More  inferiorly  we  observe  a  completely 
fibrous  sheet,  which  becomes  thicker  the  nearer  it  approximates 
the  epigastrium.  It  is  arranged  in  the  form  of  bands,  and  its 
fibres  run  obliquely  downwards  and  inwards,  in  order  to  become 
continuous  with  the  aponeuroses  of  the  belly.  It  covers  the  recti 
muscles  in  particular,  and  binds  them  down  upon  the  ribs. 

iv.  The  Muscles. 

(a)  The  pectoralis  major  is  the  thickest  and  most  powerful  of 
the  muscles  of  this  region ;  as  its  attachment  forms  a  curved  line, 
the  convexity  of  which  looks  towards  that  of  the  opposite  side, 
the  free  space  which  the  two  pectoral  muscles  leave  between 
them  upon  the  sternum,  is  broader  superiorly,  and  especially  infe- 
riorly, than  in  the  middle ;  this  disposition  is  very  distinctly  de- 
lineated through  the  skin  in  strong  muscular  individuals.  This 
muscle  is  separated  from  the  skin  by  the  thickest  part  of  the  sub- 
cutaneous layer,  and  generally  admits  of  a  communication  be- 
tween the  superficial  cellular  tissue  and  the  deep  adipo-cellular 


OF   THE    CHEST.  381 

layer,  through  the  groove  which  separates  its  clavicular  and  ster- 
nal portions.  This  communication  accounts  for  the  transporta- 
tion of  inflammation,  pus,  etc.,  although  primitively  developed 
or  formed  under  the  skin  of  the  sternal  region,  into  the  hollow  of 
the  axilla. 

(  b )  The  rectus  abdominis  comes  next.  This  muscle  is  gener- 
ally very  thin  here,  and  is  commonly  intersected  externally  by 
the  last  digitation  of  the  preceding ;  it  is  sometimes  inserted  into 
the  side  of  the  base  of  the  xiphoid  cartilage,  and  always  upon  the 
seventh  and  eighth  ribs,  so  that  it  might  more  properly  be  called 
costo-pubic  than  sterno-pubic.  Its  fibres  are  parallel  and  descend 
perpendicularly ;  and  where  they  abandon  the  ribs  in  order  to 
enter  the  epigastrium,  they  are  usually  crossed  transversely  by  a 
fibrous  intersection,  which  adheres  firmly  to  the  aponeurosis,  and 
is  much  more  complete  before  than  behind,  where  it  even  does 
not  exist  at  all. 

It  is  not  uncommon  to  see  the  superior  extremity  of  this  mus- 
cle, either  in  whole  or  in  part,  pass  much  higher,  ascending  some- 
times even  to  the  origin  of  the  sterno-mastoid,  and  thereby  bear- 
ing a  resemblance  to  the  natural  disposition  of  several  mammi- 
ferae.  At  other  times,  the  anomaly  is  independent  of  this  muscle, 
and  some  supernumerary  bundles  have  been  seen  upon  different 
parts  of  this  region.  Thus,  there  is  sometimes  a  small  distinct 
muscle  which  descends  from  the  superior  extremity  of  the  ster- 
num, where  it  is  simply  inserted  into  the  bone,  or  is  continued 
with  the  sterno-mastoideus  towards  one  of  the  sterno-costal  car- 
tilages, binding  down  the  pectoralis  major  muscle  ;  at  other  times, 
it  is  merely  a  fascis  detached  from  the  steriw-humeral  (pectoralis 
major),  sterno-mastoid  or  sterno-pubic  (rectus)  muscles,  etc.  In 
all  which  cases,  these  anormal  muscles  may  elevate  the  skin  so  as 
form  reliefs,  which  we  should  guard  against  mistaking  for  patho- 
logical swellings. 

( c )  A  small  portion  of  the  obliquus  extemus  abdominis  (costo- 
abdominal),  is  found  in  the  inferior  part  and  upon  the  external 
limits  of  this  region,  between  the  rectus,  pectoralis  major,  and  ser- 
ratus  magnus  muscles,  with  which  it  digitates. 

(d)  All  these  muscles  are  applied  directly  upon  the  bones  or 
cartilages ;  but  the  spaces  between  the  latter  are  also  filled  by 
ihe  anterior  third  of  the  intercostaks  interni,  the  fibres  of  which, 


382  OF    THE    CHEST 

directed  downwards  and  inwards,  are  a  mixture  of  fleshy  bun- 
dles and  aponeurotic  bands ;  they  are  separated  from  the  prece- 
ding by  a  cellular  layer,  which  becomes  more  distinct  as  it  re- 
moves from  the  median  line. 

( e )  Deeply  seated,  behind  the  skeleton,  between  the  carti- 
lages and  pleura,  we  find  the  triangularis  sterni  muscle,  which 
seems  to  be  continuous  externally  with  the  internal  intercostals, 
and  which  performs  an  important  part  in  the  fractures  of  the 
bones  to  which  it  is  attached.  Finally,  quite  inferiorly,  the  anterior 
portion  of  the  obliquus  intenius,  (ilio-abdominal)  muscle,  and  of  the 
diaphragm,  also  attach  themselves  to  the  inferior  border  of  the 
solid  portion  of  this  region. 

v.  The  Arteries. 

These  vessels  appertain  to  three  orders  :  they  originate  from 
the  axillary  and  subclavian  arteries,  and  from  the  thoracic  aorta. 

The  first  are  generally  small  ramuscules,  which  are  derived 
from  the  branches  of  the  anterior  thoracic,  acromial  and  external 
mammary  arteries.  They  are  lost  in  the  skin,  superficial  cellular 
layer,  pectoralis  major,  and  the  deep  lamellated  layer,  anastomo- 
sing with  the  external  branches  of  the  internal  mammary  (sub- 
sternal)  artery. 

The  internal  mammary  appertains  to  the  second  order,  and  is 
the  most  important  artery  of  this  region.  It  originates  from  the 
subclavian  opposite  to  the  vertebral  artery,  descends,  directing 
itself  forwards,  behind  the  cartilage  of  the  first  rib,  or  some  lines 
external  to  the  sterno-clavicular  articulation,  and  thus  continues 
its  course,  gradually  diminishing  in  volume,  as  far  as  the  sixth  in- 
tercostal space.  It  is  only  separated  from  the  cavity  of  the  tho- 
rax by  the  pleura  covered  by  a  cellular  layer,  and  by  the  triangu- 
laris sterni  muscle  ;  its  anterior  surface  is  in  close  contact  with 
the  cartilages  which  it  crosses,  and  is  only  removed  from  the  in- 
ternal intercostal  muscles  by  a  cellulo-adipose  layer,  which  is 
usually  very  thin.  It  lies  about  three  lines  from  the  outer  edge  of 
the  sternum ;  so  that,  superiorly,  its  ligature,  which  has  been  pro- 
posed by  some  surgeons,  would  in  fact  be  possible,  provided  cir- 
cumstances presented  themselves  actually  requiring  the  perfor- 
mance of  this  operation.  In  order  to  discover  it,  it  would  be  suf- 


OP   THE    CHEST.  383 

ficient  to  make  an  incision  two  or  three  inches  long  through  the 
skin,  parallel  to  the  margin  of  the  sternum,  and  by  preference 
upon  the  third  intercostal  space,  because  it  is  the  widest ;  then, 
we  would  have  to  divide  the  superficial  cellular  layer,  the  fibres 
of  the  pectoralis  major  muscle,  a  thin  lamellated  tissue  which  se- 
parates it  from  the  intercostal,  the  most  internal  fibres  of  the  latter, 
finally  a  cellular  layer  of  slight  thickness,  when  the  artery  will  be 
exposed.  From  the  position  and  calibre  of  this  vessel,  we  see 
that  the  thrust  of  a  sword,  or  of  any  pointed  instrument  whatso- 
ever, would  produce  a  haemorrhage  in  the  sternal  region,  espe- 
cially if  it  passed  near  the  sides  of  the  sternum,  and  that  the 
higher  the  wound,  the  greater  would  be  the  danger  from  the 
haemorrhage. 

The  principal  branches  given  oft'  from  the  internal  mammary 
are  the  anterior  and  the  external ;  the  former  traverse  the  inter- 
costal muscles  near  their  internal  extremity,  in  order  to  reach  the 
subcutaneous  layer,  where  they  inosculate  with  twigs  from  the 
axillary  artery.  In  females,  one  of  these  branches  is  sometimes  of 
considerable  size :  it  is  that  which  ramifies  in  the  mammary 
gland.  The  external  branches  pass  outwards  and  complete  the 
intercostal  arches.  These  arteries  increase  in  volume  the  lower 
they  are  given  off*.  Finally,  the  trunk  itself,  which  bifurcates 
near  the  cartilago  ensiformis,  and  one  of  its  divisions  immediately 
gives  off  a  large  twig  which  passes  before  this  appendix,  in  order 
to  form  an  arch  with  a  similar  twig  from  the  opposite  side.  This 
arch  is  sometimes  so  large  that  its  pulsations  may  be  distinguished 
through  the  skin,  and  may  occasion  haemorrhage  in  consequence 
of  wounds  received  in  the  lower  part  of  the  sternal  region. 

vi.  The  Veins. 

We  frequently  find  two  for  each  internal  mammary  artery,  and 
always  one  for  each  of  the  other  arterial  canals.  These  vessels 
are  not  very  important  in  a  surgical  point  of  view ;  except  it  is 
that  the  superficial  ones  sometimes  dilate  in  such  a  manner  as  to 
form  varicose  cords  under  the  skin,  as  we  observe,  for  example, 
in  females  affected  with  scirrhus  or  cancer  of  the  breast ;  in 
those  also  who  have  nursed  several  children,  or  who  from  a  state 
of  obesity,  have  fallen  into  marasmus  ;  finally,  in  persons  whose 


384  OF    THE    CHEST. 

venous  circulation  of  the  superior  systems  has  for  a  long  time 
been  impeded  by  an  organic  lesion  of  the  thoracic  viscera.  To 
the  subcutaneous  veins  are  also  to  be  attributed  those  peculiar 
streaks  (vergetures)  which  the  skin  upon  the  anterior  part  of  the 
chest  presents  in  certain  individuals. 

vn.  Tlie  Lymphatics. 

They  are  pretty  numerous  towards  the  axillary  and  costal  re- 
gions, and  much  more  so  in  women  than  in  men.  Those  which 
are  situated  upon  the  fore  part  of  the  pectoralis  major  muscle 
ascend  to  the  glands  of  the  neck  ;  hence  diseased  enlargements 
of  the  latter  organs,  when  the  breasts  are  affected  with  cancer. 
Those  of  the  deep  series  pass  directly  to  the  axilla,  and  also  com- 
municate with  the  lymphatics  of  the  the  thoracic  cavity.  Some- 
times there  is  a  gland  in  the  furrow  which  separates  the  inferior 
border  of  the  pectoralis  major  from  the  other  parts,  in  which  case 
this  body  is  situated  upon  the  largest  bundle  of  vessels  which  go 
from  the  sternal  region  into  the  axillary  cavity. 

The  lymphatic  system  is  here  disposed  in  such  a  manner,  that 
blisters,  issues,  as  well  as  all  chronic  diseases  with  alteration  of 
tissue,  rarely  persist  beyond  many  months  upon  the  anterior  part 
of  the  thorax,  without  re-acting  sympathetically  upon  the  glands 
in  the  sub-clavicular  hollow. 

vin.  The  Nerves. 

The  extreme  branches  of  the  intercostal  nerves  are  the  only 
ones  which  we  observe  in  the  inferior  fourth  of  this  region  ;  supe- 
riorly, it  derives  numerous  filaments  from  the  axillary  plexus, 
and  from  the  supra-clavicular  branches  of  the  cervical  plexus. 
All  these  nerves  are  of  small  volume,  and  cannot  be  of  moment 
in  operations.  But  it  is  proper  to  observe  that  all  those  which 
come  from  the  brachial  plexus  and  intercostal  branches  appear  to 
be  more  particularly  distributed  to  the  muscles,  whilst  the  cervical 
twigs  seem  rather  to  appertain  to  the  skin.  Prof.  Laennec  thinks 
that  angina  pecforis  is  frequently  nothing  more  than  a  neuralgia 
of  the  latter.  We  do  not  know  upon  what  data  this  celebrated 
physician  founds  his  opinion  ;  but  we  believe  that  what  has  been 
described  by  Rougnon,  Heberden,  and  many  English  and  French 


OF   THE     CHEST.  385 

physicians,  under  the  name  of  Angor  or  Angina  Pectoris,  is  a 
disease  which  affects  organs  of  higher  importance- than  those  un- 
der consideration. 

ix.  The  Skeleton. 

It  is  formed  by  the  whole  of  the  sternum,  the  sterno-costal  car- 
tilages, and  the  sternal  extremity  of  the  clavicle.  We  will  con- 
sider each  of  these  parts  separately. 

It  is  here  especially  that  we  must  examine  the  sterno-clavicu- 
lar  articulation.  The  osseous  surfaces  are  so  arranged  in  this 
joint  that  the  clavicular  extremity  is,  as  it  were,  merely  applied 
upon  the  sternal  facet ;  but  to  make  amends  for  this,  these  two 
bones  are  fixed  by  means  of  strong  and  very  short  ligaments, 
and  the  nature  of  the  movements  which  the  clavicle  must  exe- 
cute, prevent  it  from  being  so  often  luxated  as  might  at  first  sight 
be  imagined.  Thus,  the  clavicle  being  fixed  to  the  sternum  by  a 
species  of  capsule  which  is  very  strong  superiorly,  and,  on  the 
other  hand,  attached  to  the  supra-sternal  notch,  and  to  its  similar 
bone  of  the  opposite  side,  it  will  oppose  very  great  resistance  be- 
fore it  escapes  from  the  cavity  which  contains  it  in  this  direction. 
It  is  true,  that  when  it  is  descending,  it  acts  upon  the  first  rib  as  a 
lever  of  the  first  order ;  but  the  disposition  of  the  shoulder  in 
general,  and  of  the  scapula  in  particular,  will  almost  constantly 
prevent  this  movement  from  being  carried  so  far  as  to  effect  the 
rupture  of  the  ligaments.  The  luxation  of  the  clavicle  directly 
upwards,  therefore,  is  very  difficult,  if  not  quite  impossible. 
Posteriorly,  this  bone  makes  a  prominence  in  the  summit  of  the 
thorax,  and,  on  the  right  side,  corresponds  to  the  termination  of 
the  left'subclavian  vein,  and  to  the  arteria  innominata,  from  which 
it  is  separated  by  the  origins  of  the  sterno-thyroideus  and  sterno- 
hyoideus  muscles ;  on  the  left  side  to  the  same  vein,  and  to  the 
interval  which  separates  the  left  subclavian  and  carotid  ar- 
teries. This  prominence  is  owing,  on  the  one  part,  to  the 
head  of  the  bone  representing  a  species  of  triangle,  the  apex 
of  which  is  inclined  backwards  and  downwards  ;  on  the  other,  to 
the  great  convexity  which  the  clavicle  presents  anteriorly,  where- 
by it  is  naturally  thrown  back  a  little  in  the  opposite  direction, 
"when  it  arrives  at  the  sternum.  Notwithstanding  these  unfavour- 

49 


386  0*    THE    CHES'J*. 

able  dispositions,  posterior  luxations  of  this  bone  are  extremely 
rare ;  and  the  reason  of  it  is  found  in  the  strength  of  the  fibrous 
capsule,  of  the  costo-clavicular  ligament,  and  the  position  of  the 
scapula,  which  does  not  permit  the  transverse  lever  of  the  shoul- 
der to  advance  sufficiently  forwards  to  produce  the  luxation.  In- 
feriorly,  the  two  bones  being  in  contact,  every  species  of  displace- 
ment is  impossible  ;  but  it  is  not  so  anteriorly.  In  fact,  on  this 
side,  the  articulation  is  only  supported  by  the  sternal  tendon  of 
the  sterno-mastoideus  muscle,  which  is  also,  most  frequently,  too 
much  approximated  to  the  median  line  ;  and  by  the  anterior  lig- 
ament, or  capsule,  which  is  weaker  than  in  the  other  directions. 
Besides,  nothing  limits  the  movements  of  the  clavicle  backwards, 
and  the  anterior  surface  of  the  shoulder  presents  itself  much 
more  advantageously  to  external  powers  than  the  posterior,  in  or- 
der to  produce  this  movement :  there  is  nothing  surprising  then 
in  the  luxation  forwards  being  the  most  frequent,  and  almost  only 
possible  one. 

The  sternum  is  about  eight  lines  in  thickness,  which  thickness 
is  mere  considerable  opposite  to  the  cartilages  than  to  their  inter- 
vals, and  still  greater  in  the  clavicular  portion  of  the  bone  (manu- 
brium).  In  childhood  it  consists  of  different  pieces,  which  some- 
times preserve  their  mobility  in  the  adult  age,  especially  the  first 
two.  It  is  proper  to  recollect  these  peculiarities,  as  they  might 
sometimes  be  mistaken  for  fractures.  Occasionally  also  the  pri- 
mi-sternal  and  the  duo-sternal,  in  uniting,  leave  a  hole  which  is 
only  filled  by  a  fibrous  or  fibro-cellular  tissue,  and  which  might  in- 
duce the  belief  that  the  operation  of  trephining  had  been  perfor- 
med ;  this  foramen  might  also  permit  instruments  to  penetrate 
more  easily  into  the  chest,  and  thus  render  wounds  in  this  situa- 
tion more  serious  :  at  other  times  the  lateral  points  of  ossification 
do  not  coalesce  upon  the  median  line  ;  the  sternum  then  remains 
bifid  in  its  inferior  fourth,  third,  and  even  half,  and  nothing  would 
then  be  more  easy  than  to  wound  the  central  organs  of  the  tho- 
rax, through  a  similar  division.  The  xiphoid  appendix  sometimes 
projects  outwards,  and  stretches  the  skin  so  much,  in  thin  sub- 
jects, as  to  occasion  its  ulceration  ;  neither  is  it  more  uncommon 
to  see  it  curved  backwards  ;  and  as  it  corresponds  to  the  stom- 
ach, it  might  impair  the  digestive  functions,  and  occasion  symp- 
toms similar  to  those  which  characterise  gastralgia.  It  is  also 


OF   THE    CHEST.  387 

well  to  know  that  this  cartilage  may  incline  to  the  right,  to  the  left, 
and  in  all  possible  directions ;  that  sometimes  it  is  blunt,  at  others 
acute,  and  again  bifid,  even  when  the  sternum  is  well  formed. 
In  general,  the  form  of  the  region  under  examination  is  deter- 
mined bv  that  of  the  sternum,  and  it  is  of  importance  to  note 
this  form,  on  account  of  the  influence  which  it  exercises  upon  the 
functions  of  the  heart  and  lungs.  Thus,  when  this  bone  is  very 
protuberant,  as  is  the  case  in  the  natural  state  in  children,  the 
movements  of  the  heart  are  very  free  ;  but  the  lungs  are  pressed 
against  the  sides  of  the  pericardium ;  when  on  the  contrary  it  is 
convex  backwards,  the  circulatory  organs  are  compressed,  as  it 
were,  upon  the  spine,  whilst  those  of  respiration  distend  freely  on 
each  side. 

As  the  upper  and  right  portion  of  the  sternum  is  very  near  to 
the  arteria  innominata,  (brachio-cephalic  trunk,)  some  have  sup- 
posed that,  by  trepanning  this  bone  immediately  below  and  with- 
in the  clavicle,  we  would  easily  reach  the  artery ;  but  this  ope- 
ration, though  not  very  difficult  upon  the  dead  body,  must,  in  our 
opinion,  be  of  very  difficult  performance  upon  the  living  subject. 

M.  Laennec  has  also  advised  the  application  of  the  crown  of 
the  trephine  upon  the  left  inferior  third  of  the  sternum,  with  the 
intention  of  opening  the  fibrous  envelope  of  the  heart  in  cases  of 
hydrops  pericardii :  then,  it  would  be  necessary  to  recollect  that 
this  bone  is  thinner  inferiorly  than  in  its  superior  portion.  Al- 
though the  sternum  is  destined  to  protect  organs  of  the  first  im- 
portance, it  may  be  diseased,  in  great  part  disorganised,  and  even 
destroyed,  without  the  life  of  the  individual  being  thereby  truly 
endangered.  The  case  related  by  Galen,  and  since  so  frequently 
repeated  ;  that  mentioned  by  Harvey,  in  which  the  bone  was 
perforated  in  such  a  manner  that  the  heart  was,  as  it  were  uncov- 
ered, are  incontestable  proofs  of  it ;  so  that  if  blood,  pus,  or  any 
other  fluid  was  accumulated  in  the  anterior  mediastinal  space, 
and  the  evacuation  of  the  morbid  product  might  save  the  pa- 
tient, we  should  without  apprehension  apply  the  trephine  here. 
Besidesj  the  bone  is  so  soft  and  spongy,  in  the  greater  proportion 
of  adults,  that  it  would  be  easy  to  perforate  it,  even  with  the 
knife.  This  softness,  which  is  owing  to  its  great  vascularity,  also 
accounts  for  the  frequency  of  its  diseases,  and  for  its  being  less 
subject  to  necrosis  than  caries.  As  the  sternum  is  susceptible  of 


388  OF    T11K    CiiEST. 

elevation  and  depression  during  respiration,  and  is  suspended,  as 
it  were,  by  the  extremity  of  flexible  cartilages ;  as  it  is  likewise 
flexible  itself  to  a  certain  extent,  its  fractures  must  be  very  diffi- 
cult to  produce,  and  even  seem  impossible  unless  by  a  direct 
cause  ;  in  fact,  we  can  scarcely  conceive  it  possible  for  it  to  be 
acted  upon  by  two  different  powers  which  would  tend  to  approx- 
imate its  extremities  towards  each  other.  There  is,  however,  an 
example  of  fracture  by  counter  stroke,  related  by  David,  and 
registered  in  the  Mem.  de  Vacademie  royale  de  chirurgie,  in 
which  we  see  that  a  man  fell  from  a  great  height  upon  the  ensi- 
forme  cartilage  and  fractured  the  sternum  through  its  middle. 
In  these  fractures,  by  whatever  cause  they  may  have  been  pro- 
duced, the  internal  derangements,  consequent  upon  them,  must 
occupy  more  of  the  surgeon's  attention  than  the  lesion  of  the 
bone :  it.  is  possible,  however,  that  one  of  the  fragments  may  be 
displaced  backwards;  in  which  case  it  would  not  fail  to  occa- 
sion serious  disturbance  of  the  heart  or  principal  vascular  trunks. 
Finally,  on  account  of  its  spongy  nature,  its  great  vitality,  and  its 
being  interposed  between  two  fibrous  layers  of  a  certain  thick- 
ness, the  sternum  is  very  promptly  consolidated ;  but,  in  order 
that  this  consolidation  may  take  place,  it  is  necessary  that  the 
fragments  should  be  retained  immoveable,  which  is  easily  done, 
by  obliging  the  respiration  to  be  performed  solely  by  the  dia- 
phragm. 

The  sterno-costal  cartilages,  elastic  and  flexible,  uniting  the 
first  seven  ribs  to  the  sternum,  and  applying  the  last  five  to  each 
other  by  the  anterior  extremities  of  their  inferior  border,  are  so 
disposed  that  the  first  is  the  shortest,  broadest,  strongest  and  the 
most  firmly  united  to  the  two  bones  which  it  connects  ;  and  it  is 
this  last  circumstance  especially  which  prevents  the  first  rib  from 
being  more  moveable  than  the  following  ones,  and  which  supports 
the  clavicle.  In  examining  the  others  in  succession,  we  find 
that  their  length  and  mobility  increase  as  far  as  the  seventh 
inclusively ;  although  the  last  five  gradually  diminish  in  length, 
they  are  still  more  moveable,  because  their  union  only  takes  place 
by  means  of  facets  which  admit  of  a  more  or  less  extensive  sli- 
ding motion  (glissement),  and  because  they  are  also  much  thin- 
ner :  whence  it  follows  that  they  are  very  seldom  fractured, 
whilst  the  former  are  pretty  frequently  broken.  But  whether 


OF   THE     CHEST.  389 

these  fractures  are  produced  by  direct '  or  indirect  causes,  if  the 
fragments  are  susceptible  of  crossing  each  other,  the  displace- 
ment will  almost  always  take  place  in  such  a  manner  that  the 
sternal  will  pass  before  the  costal  portion ;  and  for  this  reason, 
because  the  pectoralis  major  muscle  acts  with  more  or  less  force 
upon  the  former,  whilst  the  triangularis  sterni  tends  to  draw  back 
the  latter.  The  fracture  is  always  transversal,  and  the  nature  of 
the  cartilage  singularly  modifies  here  the  disposition  of  the  callus. 
In  fact,  although  Autenrieth  has  stated  that  the  costal  cartilages 
reunite  after  their  fracture,  MM.  Magendie,  Lobstein,  Beclard, 
etc.,  have  observed  that  the  two  fragments  do  not  become  ag- 
glutinated, and  that  their  perichondrium  alone  experiences  a 
transformation,  or  such  changes,  that  it  at  length  forms  an  osseous 
hollow  cylinder,  in  the  centre  of  which  the  two  cartilaginous  ex- 
tremities are  encased ;  in  short,  that  the  restorative  efforts  of  na- 
ture are  limited  to  what  Duhamel,  Fougeroux,  M.  Pelletan  Senr. 
etc.  have  described  as  the  principal  phenomenon  of  reunion,  in 
fractures  in  general,  or  rather  to  what  M.  Dupuytren  calls  the  pro- 
visory callus  in  the  long  bones ;  that  is  to  say,  that  this  union  is 
effected  entirely  at  the  expense  of  the  fibrous  envelope.  It  is 
necessary  to  note,  however,  that  these  cartilages  frequently  be- 
come ossified  as  age  progresses,  and  that  the  same  sometimes 
occurs  in  certain  diseases  of  the  chest,  in  phthisis,  for  example ; 
then  their  fractures  must  take  place  more  readily  and  the  callus 
form  as  in  the  long  bones.  On  the  other  hand,  their  cartilagin- 
ous state  has  been  found  to  persist  in  persons  who  have  prolonged 
their  existence  to  a  very  advanced  period ;  to  one  hundred  and 
thirty  years,  (Kiel,)  and  even  to  one  hundred  and  fifty,  (Harvey). 
The  first  three  inter-cartilaginous  spaces  are  broader  than  those 
which  follow  them ;  the  sixth  is  already  very  much  contracted, 
and  this  is  one  reason  why  we  should  choose  the  fifth,  if  we  wish- 
ed to  open  the  pericardium,  according  to  the  method  undertaken 
by  Desault.  In  this  point,  we  would  not  be  obliged  to  divide  the 
pectoralis  major ;  the  rectus  muscle  is  here  very  thin,  and  fre- 
quently does  not  ascend  so  high ;  the  pericardium  also  is  nearer 
to  this  space  than  any  other,  and  the  internal  mammary  artery 
bifurcates  lower  down.  Consequently,  we  would  have  to  divide 
the  skin,  the  superficial  layer  in  some  subjects,  some  fibres  of  the 
pectoralis  major  muscle,  or  the  aponeurosis,  a  second  cellular 


390  OF    THE    CHEST. 

layer  thinner  than  the  first,  the  internal  intercostal  muscle,  addi- 
tional cellular  laminae,  the  pleura,  finally  the  pericardium,  taking 
care  to  leave  the  internal  mammary  artery  on  the  inner  side,  and 
to  avoid  the  anterior  margin  of  the  lung,  which  must  be  pushed 
outwards.  It  is  needless  to  say  that  we  are  speaking  of  the  left 
side. 

From  what  has  preceded,  we  see  that  wounds  upon  the  median 
line,  in  the  sternal  region,  would  fall  directly  upon  the  heart  or 
large  vessels,  whilst  upon  the  sides  they  would  also  encounter  the 
lungs.  We  will  see,  when  examining  the  internal  organs,  the 
dangers  of  their  lesions,  according  to  the  points  upon  which  they 
are  inflicted.  We  will  only  observe,  by  anticipation,  that  pene- 
trating wounds  made  by  pointed  or  cutting  instruments,  will  be 
more  dangerous  when  they  simply  pass  through  the  thoracic  par- 
ietes  in  the  inferior  intercostal  spaces  and  near  the  sternum,  than 
at  the  superior  part,  on  account  of  the  internal  mammary  and  its 
branches. 

We  will  further  remark  that  a  transverse  wound,  before  and 
upon  the  sides  of  the  supra-sternal  notch,  might  produce  two 
kinds  of  accidents :  one,  relative  to  the  sterno-clavicular  articula- 
tion, which  would  then  be  easily  opened,  and  the  other  to  the  di- 
vision of  the  sterno-mastoid  muscle.  The  sternal  portion  of  this 
muscle,  in  fact,  descends  so  low  in  some  persons,  that  it  might 
possibly  be  divided  upon  the  fore  part  of  the  sternum,  and  as  it 
is  this  muscular  portion  which  supports  the  upper  part  of  the 
chest  in  full  inspirations,  great  exertions,  etc.,  serious  changes  in 
the  exercise  of  these  phenomena  would  result  from  it. 

All  these  parts  are,  besides,  arranged  in  the  following  order ; 
1st,  the  skin,  thick  and  compact  in  the  sternal  gutter,  supple  and 
extensible  upon  the  lateral  parts ;  2d,  the  subcutaneous  layer, 
divisible  into  three  laminae  before  the  pectoralis  major  muscle, 
where  it  is  sometimes  very  thick,  fibrous  upon  the  median  line, 
and  in  which  arterial  twigs,  nervous  filaments  and  veins  more  or 
less  voluminous,  ramify ;  3d,  the  aponeurosis,  distinct  in  the  infe- 
rior fourth  of  the  region  only  ;  4th,  the  pectoralis  major  muscle, 
a  small  portion  of  the  rectus  abdominis,  a  very  small  part  of  the 
tendons  of  the  sterno  mastoideus  ;  it  is  in  this  stratum  that  we 
find  the  principal  arteries  and  the  deep  nerves  ;  5th,  the  sternum, 
cartilages,  intercostal  muscles ;  6th,  a  lamellated  layer,  the  inter- 


OP   THE    CHEST,  391 

nal  mammary  artery  ;  7th,  the  triangularis  sterni  muscle  and  the 
pleura. 

Sect.  2.  Posterior  Region. 

This  portion  of  the  thorax  is  bounded  superiorly  by  the  poste- 
rior region  of  the  neck ;  inferiorly,  by  a  curved  line  similar  to 
that  which  limits  the  sternal  region  below,  that  is  to  say  by  a 
line  which  runs  along  the  inferior  margin  of  the  twelfth  ribs,  in 
order  to  pass  upon  the  spinous  process  of  the  twelfth  dorsal  ver- 
tebra ;  laterally,  by  a  line  which  arbitrarily  prolongs  the  vertebral 
border  of  the  scapula  upon  the  union  of  the  posterior  third  of  the 
crista  of  the  ilium  with  its  two  anterior  thirds,  and  which  would 
consequently  follow  the  prominence  formed  by  the  angles  of  the 
ribs  :  we  will  call  this  the  scapulo-coxal  line. 

Upon  the  surface  of  this  region,  in  the  inter-scapular  portion 
and  upon  the  median  line,  we  observe  a  ridge,  in  general  not  very 
prominent,  and  which  is  produced  by  the  vertebral  spinous  pro- 
cesses ;  upon  the  sides  of  this  ridge,  two  grooves  or  gutters,  vary- 
ing in  depth  in  different  subjects;  more  externally,  two  eminen- 
ces which  correspond  to  the  muscular  masses,  and  which  become 
more  prominent  in  proportion  as  the  shoulder  is  carried  forwards ; 
finally,  the  posterior  margin  of  the  scapula,  which  changes  its  po- 
sition during  each  movement  of  the  superior  extremity,  and 
which  is  also  more  or  less  prominent  according  to  the  conforma- 
tion of  the  thorax. 

In  the  inferior  part  of  the  region,  the  median  ridge  is  pretty 
frequently  very  prominent,  the  lateral  grooves  are  also  much 
deeper  and  the  muscular  eminences  larger  than  in  the  superior 
portion.  This  difference  arises  from  the  spine  being  very  convex 
above,  whilst  below  it  is  inclined  in  the  opposite  direction  ;  from 
the  spinous  processes  being  very  oblique  superiorly,  and  horizon- 
tal inferiorly.  As  the  lateral  convexities  depend  as  much  upon 
the  curvature  of  the  ribs  as  upon  the  prominence  formed  by  the 
muscles,  we  will  always  increase  them  by  carrying  the  arms  for- 
wards, so  as  to  cross  them  upon  the  fore  part  of  the  chest,  or 
over  the  head,  for  example  ;  which  it  is  necessary  to  do,  when 
we  endeavor  to  ascertain  the  state  of  the  lungs,  or  of  the  other 
thoracic  viscera,  by  percussion  or  auscultation. 


392  OF   THE    CHEST. 


CONSTITUENT   PART?. 

i.  The  Skin. 

It  is  thicker  than  that  of  the  posterior  part  of  the  neck,  but 
does  not  otherwise  differ  from  it,  except  in  its  slighter  adhesion 
to  the  muscles  and  its  firmer  union  to  the  spinous  processes  of 
the  vertebrae.  It  contains  a  great  number  of  sebaceous  follicles, 
but  is  destitute  of  hairs  and  wrinkles ;  it  is  very  dense  and  its 
sensibility  very  great,  although  it  does  not  receive  many  nerves ; 
the  acute  pains  which  are  manifest  in  it,  when  it  becomes  the  seat 
of  boils,  carbuncles,  erysipelatous  or  other  inflammations,  evi- 
dently depend  upon  these  two  circumstances,  and  by  the  latter 
we  can  account  for  the  numerous  and  extensive  sympathies 
which  its  artificial  or  natural  irritations  bring  into  action.  Thus, 
every  body  knows,  that  an  epistaxis  is  frequently  and  immedi- 
ately arrested  by  applying  a  key,  or  any  cold  metallic  body,  as 
well  as  linen  steeped  in  refrigerant  liquids,  etc.,  between  the 
shoulders.  It  is  also  founded  upon  these  results  that  we  have 
applied  upon  this  part,  and  with  immediate  success,  cataplasms  of 
mustard,  in  cases  of  uterine  hemorrhages  occurring  immediately 
after  parturition,  or  at  the  expiration  of  a  few  days,  which  had 
resisted  other  rational  means,  and  threatened  to  become  speedily 
mortal. 

ii.  The  Subcutaneous  Layer. 

Divisible  into  several  lamina?  by  maceration,  it  is  compact, 
dense,  and  forms  a  complete  fascia  superficialis.  This  layer  is 
composed  of  a  larnellated  and  filamentous  cellular  tissue,  in  which 
are  soft,  reddish  and  elongated  adipose  cells,  capable  of  consider- 
able enlargement,  and  of  forming  a  fatty  stratum  of  a  certain 
thickness  in  persons  who  have  much  embonpoint.  It  is  not  unu- 
sual to  see  some  of  them  agglomerate,  and  thus  enlarge  together 
so  as  to  produce  lipomatous  tumours,  which  sometimes  become  of 
a  considerable  volume.  But  this  pathological  developement  of 
the  fatty  vesicles  can  only  take  place  upon  the  sides,  because, 
upon  the  median  line,  the  cellular  layer,  under  consideration, 


OF   THE    CHEST. 


392 


unites  the  vertebras  intimately  to  the  skin  ;  and  it  is  also  for  this 
reason,  that  infiltrations,  abscesses,  collections,  and  tumours  of 
every  kind,  with  the  exception  of  those  which  depend  upon  dis- 
eases of  the  bones,  never  manifest  themselves  in  the  middle  of 
the  dorsal  region. 

This  layer  may  inflame  and  suppurate  ;  but,  as  it  is  interposed 
between  two  planes  which  offer  much  resistance,  purulent  ab- 
scesses form  in  it  very  slowly,  extend  in  breadth,  and  sometimes 
persist  a  long  time  before  they  project  externally  ;  the  skin  which 
covers  them  may  preserve  its  thickness  and  the  greater  part  of 
its  other  characters  during  several  months.  If  the  inflammatory 
phenomena  are  not  very  acute,  the  collection  will  be  called  a 
a  chronic  abscess,  or  be  mistaken  for  a  purulent  deposition  (depot 
par  congestion!),  and  finally  produce  the  death  of  the  patient, 
As  these  abscesses  are  limited  anteriorly  by  the  thickened  aponeu- 
rosis,  they  may  burrow  extensively,  even  from  the  posterior  part 
of  the  neck  into  the  lumbar  region.  It  seems  evident  to  us,  that,  in 
cases  of  this  nature,  the  danger  proceeds  from  the  resistance  of 
the  tissues,  which  oppose  the  evacuation  of  the  diseased  secre- 
tions, and  that  the  best  means  of  saving  the  patients,  would  be  to 
open  early  and  freely  the  cavities  in  which  they  are  contained. 

3.  The  Aponeurosis. 

In  some  places  it  is  composed  of  thin  cellular  Iamina3  of  but 
slight  strength ;  in  others,  it  is  thick  and  strong.  Thus,  the  an- 
terior and  posterior  surfaces  of  the  trapezius  and  latissimus  dorsi 
are  covered  by  a  thin  and  extensible  sheet,  which  adheres  to 
them  firmly,  the  layers  of  which  are  applied  together  and  blend- 
ed near  the  inferior  angle  of  the  scapula,  in  the  small  triangu- 
lar space  which  separates  these  two  muscles,  so  as  to  form  a 
more  distinct  lamina.  Another  aponeurotic  sheet  binds  down 
the  muscles  of  the  vertebral  gutters,  and  is  prolonged  upon  the 
splenius  to  the  neck,  splitting  in  order  to  envelope  the  serratus 
posticus  superior,  confounded  below,  upon  the  serratus  posticus 
inferior,  with  the  aponeurosis  of  the  lumbar  region,  and  inserted 
into  the  spinous  processes  of  the  dorsal  vertebrae  on  the  one  hand, 
and  upon  the'  angles  of  the  ribs  on  the  other.  In  other  words, 
the  very  strong  aponeurosis  of  the  latissimus  dorsi  may  be  con- 

50 


394  OF    THE    CHEST. 

sidered  as  furnishing  envelopes  to  all  the  muscles  of  the  back, 
and  especially  a  very  regular  sheet,  which  serves  to  separate  the 
muscles  which  form  the  superficial  stratum  from  those  of  the 
deep  stratum.  These  different  sheets  are  too  thin,  and  do  not 
sufficiently  assume  the  aponeurotic  characters  to  become  the 
causes  of  serious  accidents  in  deep-seated  inflammations  of  the 
back  ;  but,  in  becoming  blended,  as  it  were,  with  the  superficial 
muscles,  they  form  a  strong  layer,  which  prevents  the  abscesses, 
indicated  in  the  preceding  paragraph,  from  penetrating  under  the 
shoulder,  etc. 

iv.  Tlie  Muscles. 

Those  which  form  the  superficial  stratum  are  flat  and  of 
greater  or  less  breadth ;  the  deeper  seated  are  long  and  collected 
into  a  mass. 

The  former  comprise, 

(  a  )  The  inferior  half  of  the  tmpezii,  which  here  represents 
a  triangle,  the  apex  of  which  is  situated  upon  the  last  dorsal  ver- 
tebra, whilst  the  two  angles  of  its  base  terminate  upon  the  spine 
of  the  scapula ;  so  that,  in  order  to  render  these  muscles  tense,  it 
is  necessary  to  carry  the  arms  more  or  less  forwards ;  and  the 
principal  effect  of  their  contractions  must  be  to  raise  the  shoul- 
ders, at  the  same  time  that  they  approximate  the  two  scapula?  to 
the  chest  and  spine.  The  trapezius  is  covered  by  a  fibre-cellu- 
lar lamina  which  appertains  to  the  aponeurosis,  by  the  subcuta- 
neous layer  and  by  the  skin ;  it  is  separated  from  the  deep  stra- 
tum by  the  rhomboidei,  latissimus  dorsi,  and  some  lamellae  of 
cellular  tissue. 

(  b  )  A  considerable  portion  of  the  latissimus  dorsi,  and  es- 
pecially of  its  aponeurotic  origin,  since  it  ascends  to  the  fifth 
vertebra  of  this  region ;  its  fibres  are  transverse  or  slightly  ob- 
lique, and  derive  their  fixed  point  from  this  region.  This  mus- 
cle is  covered  by  the  trapezius,  the  superficial  layer  and  the  skin, 
and  is  pretty  firmly  united  to  the  serratus  posticus  inferior ;  but  it 
adheres  to  the  deep  aponeurosis  only  by  means  of  some  soft,  and 
extensible  cellular  lamellse.  When  it  emerges  from  under  the 
trapezius,  near  the  angle  of  the  scapula,  it  forms  the  inferior 
border  of  the  small  triangular  space  mentioned  when  on  the 


OF   THE    CHEST. 

posterior  region  of  the  shoulder,  and  through  which  an  instru- 
ment might  penetrate  into  the  cavity  of  the  axilla,  without  divi- 
ding any  other  muscles  than  the  serratus  magnus.  It  is  also 
through  this  kind  of  aperture,  that  pus  or  other  fluids  might  pass 
from  the  dorsal  region  into  the  summit  of  the  lateral  region,  be- 
tween the  side  of  the  thorax  and  the  serratus  magnus  muscle, 
ascend  into  the  supra-clavicular  region,  or  descend  into  the  cos- 
tal region,  or  finally  pass  from  all  these  regions  into  that  which  we 
are  now  considering.  Since  the  use  of  the  latissimus  dorsi  mus- 
cle is  to  draw  down  the  arm  and  carry  the  inferior  angle  of  the 
scapula  backwarks,  it  is  necessary,  in  order  to  make  it  tense,  and 
render  the  portion  of  the  back  which  it  covers  more  prominent, 
when  we  wish  to  exercise  percussion  or  apply  the  stethoscope 
to  this  part  of  the  chest,  to  cross  the  superior  extremities  over 
the  crown  of  the  head. 

(  c  )  The  whole  of  the  rftomboideus  major>  (rhombo'ide  dor- 
sal,) as  well  as  a  small  part^of  the  rhomboideus  minor  (rhombo'ide 
cervical)  mucles.  They  are  separated  from  the  trapezius  by  a 
thin  layer  of  cellular  tissue,  and  conceal  the  serratus  posticus 
superior ;  their  distance  from  the  angle  of  the  ribs  varies  accor- 
ding to  the  position  of  the  shoulder,  and  the  intervening  space 
is  filled  with  supple  and  very  lax  cellular  lamellae,  in  which  adi- 
pose vesicles  are  seldom  met  with.  This  space  is  prolonged  be- 
tween the  costal  portion  of  the  axilla  and  the  serratus  magnus 
muscle,  which  separates  it  from  the  cavity  of  the  axilla ;  it  com- 
municates directly  with  the  supra-clavicular  region  ;  and,  as  the 
cellular  tissue  which  fills  it  is  very  extensible  and  very  soft,  it  fol- 
lows that  fluids,  accumulated  in  the  lateral  part  of  the  neck,  soon 
descend  between  the  ribs,  the  rhomboidei  and  the  serratus  an- 
ticus.  As  the  rhomboideus  major  muscle  originates  from  the 
spinous  processes  of  the  back,  and  is  inserted  into  the  vertebral 
border  of  the  scapula  by  means  of  an  arched  aponeurotic  cord, 
it  can  only  act  upon  the  shoulder,  which  it  draws  backwards 
towards  the  median  line  and  upwards,  if  it  contracts  alone,  or 
directly  backwards  when  it  acts  in  concert  with  the  trapezius. 

(  d  )  The  serrati  postici.  The  superior  passes  obliquely  down- 
wards from  the  first  dorsal  spines  to  the  external  part  of  the  an- 
gle of  the  three  ribs  which  follow  the  first ;  the  inferior,  from  the 
spinous  processes  of  the  first  three  lumbar  and  last  two  dorsal 


39(>  OP   THE    CHEST. 

- 

vertebrae  to  the  posterior  part  of  the  twelfth,  eleventh,  tenth, 
and  ninth  ribs  ;  so  that  their  common  action  is  to  pull  the  osseous 
arches  of  the  thorax  backwards  and  outwards,  and  that  the  first 
raises  these  bones,  whilst  the  second  draws  them  dowTi.  Con- 
sequently, when  the  ribs  are  fractured  through  their  middle,  they 
must  tend  to  displace  the  posterior  fragment  outwards  and  down- 
wards, or  outwards  and  upwards,  according  to  the  situation  in 
which  the  solution  of  continuity  exists. 

The  latter,  or  the  deep-seated  muscles,  are  less  important  in  a 
surgical  point  of  view  than  the  preceding ;  they  fill  the  vertebral 
gutters,  and  comprise  the  dorsal  portion  of  the  interspinales  dorsi 
et  lumborum,  of  the  sacro-lumbalis,  of  the  longissimus  dorsi,  of  the 
semi-spmalis  dorsi  and  multifidus  spinae,  and  besides  the  origins 
of  the  complexus,  splenius  and  transversalis  colli.  All  these  mus- 
cles are  separated  from  the  superficial  layer  by  the  aponeurosis 
of  the  serrati  postici ;  they  can  only  act  upon  the  spine  and  the 
posterior  extremity  of  the  ribs.  The  external  tendons  of  the 
longissimus  dorsi  are  inserted  near  the  angle  of  these  bones,  and 
the  chest  is  dilated  during  their  contraction,  which  also  favours 
expiration.  The  levatores-costarum  muscles  are  partly  covered 
by  the  latter,  and  descend  obliquely  outwards  from  the  external 
part  of  one  costo-transverse  articulation  to  the  rib  which  is  below 
it,  being  prolonged  upon  the  second  also.  They  are  entirely  in- 
cluded in  the  dorsal  region,  and  are  continuous  below  with  the 
external  intercostal  muscles.  Their  use  is  to  elevate  the  ribs,  as 
was  well  observed  by  Verheyen  and  Steno.  In  fractures,  they 
act  in  the  same  manner  as  the  serratus  posticus  superior,  and 
counterbalance  the  action  of  the  inferior,  and  of  the  external 
bundles  of  the  longissimus  dorsi.  With  respect  to  the  intercos- 
tals,  they  present  nothing  particular  in  this  region,  and  we  only 
find  in  it  the  origins  of  the  external. 

v.  The  Arteries. 

There  are  none  so  large,  with  the  exception  of  the  intercos- 
tals,  as  to  occasion  a  profuse  haemorrhage  in  wounds  of  this 
region.  One  of  the  branches  of  the  descending  cervical,  origi- 
nating from  the  subclavian,  ramifies  before  the  rhomboideus 
muscle,  and  is  generally  distributed  to  the  superficial  muscular 


OP   THE    CHEST. 

layer,  previous  to  anastamosing,  in  the  latissimus  dorsi  muscle, 
with  the  subscapulary  artery,  and  in  this  manner  forming  an  ar- 
terial arch  which  unites  the  subclavian  to  the  brachial.  Each 
intercostal  artery  here  gives  off  its  posterior  branch,  which  passes 
between  the  bodies  of  the  vertebrae,  the  inferior  costo-transversal 
ligament,  and  two  transverse  processes,  in  order  to  enter  between 
the  sacro-lumbahs  and  inter-spinales  dorsi  muscles,  where  it  after- 
wards divides.  Then  one  of  the  branches  approximates  the 
median  line,  as  it  passes  towards  the  skin ;  the  other,  on  the  con- 
trary, removes  from  it,  and  penetrates  between  the  sacro-lumbalis 
and  longissimus  dorsi  muscles,  in  its  course  towards  the  super- 
ficial layer  and  skin,  where  it  terminates :  finally,  the  intercostal 
artery  itself,  included  in  the  space  of  the  same  name,  passes 
through  this  region,  and  in  such  a  manner  that  it  does  not  actually 
enter  its  protecting  groove  in  the  rib,  until  it  has  arrived  near  the 
angle  of  this  bone :  it  is  yet  so  remote  from  it,  opposite  to  the 
apex  of  the  transverse  process,  that  an  instrument  penetrating 
through  the  intercostal  space  might  easily  strike  it.  But,  let  us 
admire  here,  as  in  a  multitude  of  other  points,  the  disposition  of 
parts  ;  in  fact,  the  thick  muscular  mass  which  protects  this  vessel 
posteriorly  against  the  action  of  foreign  bodies,  becomes  thinner 
and  thinner  in  proportion  as  it  passes  outwards  ;  but  then  the  ar- 
tery, which  was  at  first  free  below  the  rib,  afterwards  approximates 
so  close  to  it,  that  it  is  almost  entirely  situated  under  its  internal 
surface.  In  general,  the  nerve  which  accompanies  it  runs  along 
its  inferior  border,  and  frequently  it  gives  off  its  descending 
branch  before  it  enters  into  the  costal  region. 


vr.  The  Veins. 

These  vessels  have  the  same  distribution  as  the  arteries :  they 
all  pass  to  the  azygos  veins  through  the  medium  of  the  intercos- 
tals,  and  into  those  of  the  arm  and  neck  by  the  cervical  and  sub- 
scapulary  veins. 

vu.  The  Lymphatics. 
They  are  very  few  in  number,  and  merit  still  less  attention 


398  OP    THE    CHEST. 

than  the  veins.  Those  of  the  deep  stratum,  for  the  most  part, 
enter  into  the  axillary  glands ;  almost  all  of  the  superficial,  into 
the  supra-clavicular  region :  hence,  from  this  disposition,  diseases 
of  the  skin  and  of  the  cellulo-adipose  layer  must  re-act  more 
particularly  upon  the  lymphatic  glands  of  the  neck,  whilst  affec- 
tions of  the  deep-seated  parts  will  produce  tumefaction  of  those 
in  the  cavity  of  the  axilla. 

vin.  The  Nerves. 

Besides  the  spinal  accessory,  which  is  lost  in  the  trapezius 
muscle,  some  filaments  of  the  deep  branches  of  the  cervical 
plexus,  which  extend  as  far  as  the  rhomboideus  major  and  ser- 
ratus  posticus  inferior,  and  some  others  derived  from  the  brachial 
plexus,  the  dorsal  region  also  receives  the  posterior  branches  of 
the  spinal  nerves.  These  last  follow  the  arteries,  divide  in  the 
same  manner,  and  ramify  in  the  superficial  layer  and  the  skin. 
The  intercostal  nerve,  inferior  to  the  artery,  equally  places  itself 
under  the  margin  of  the  rib,  and  sometimes  divides  before  it 
abandons  the  dorsal  portion  of  the  thorax. 

ix.  The  Skeleton. 

It  is  composed  of  the  twelve  dorsal  vertebrae  and  of  the  ribs, 
as  far  as  the  angle  or  posterior  curvature  of  the  latter.  The 
former  are  so  arranged  that  their  body,  which  is  more  extensive 
in  the  antero-posterior  direction  than  transversely,  forms  a  spe- 
cies of  column  which  is  concave  anteriorly,  and  which  advances 
in  the  thorax.  This  anterior  concavity,  which  is  owing  to  the 
vertebrae  and  the  intervertebral  fibro-cartilages  possessing  a  great- 
er degree  of  thickness  behind  than  before,  presents  almost  infinite 
gradations.  In  new-born  children,  it  scarcely  exists ;  in  old  peo- 
ple, it  is  generally  very  much  developed  ;  much  slighter  in  woman 
than  in  man,  in  persons  who  habitually  keep  themselves  erect 
than  in  those  who  bend  over  their  work,  it  may  increase  consid- 
erably, or  totally  disappear  in  consequence  of  rachitis.  In  the 
first  case,  a  gibbosity  is  produced,  and  the  sternal  region  is  then 
more  or  less  depressed ;  in  the  second,  the  dorsal  region  appears 
very  much  excavated,  and  the  sternum  projects  more  or  less 


OP   THE    CHEST.  399 

forwards.  Another  curvature  is  observed  upon  the  left  side  and 
in  the  superior  third  of  the  column,  at  the  place  upon  which  the 
aorta  rests  in  the  chest.  This  last  concavity  varies  less  than  the 
preceding  in  a  well-formed  subject;  but  in  rachitis  it  perhaps 
more  frequently  passes  beyond  its  natural  limits,  and  concurs 
very  much  in  the  production  of  gibbosity.  The  formation  of  these 
curvatures,  moreover,  is  very  easily  accounted  for,  and  upon  me- 
chanical principles ;  it  is  owing  to  the  weight  of  the  body  and 
the  action  of  the  muscles.  Thus,  as  the  head  preponderates  for- 
wards instead  of  backwrards,  the  posterior  muscles,  in  order  to 
maintain  the  equilibrium,  are  kept  in  a  state  of  almost  permanent 
contraction,  and  cannot  fail  to  make  the  cervical  portion  of  the 
vertebral  column  project  forwards.  The  weight  of  the  viscera 
of  the  thorax,  on  the  one  part ;  that  of  the  head  and  neck  on  the 
other,  tend  to  pull  the  upper  part  of  the  chest  forwards  ;  but  as 
the  line  of  gravity  wrould  not  fail  to  pass  beyond  the  base  of  sup- 
port, in  order  to  prevent  the  fall  and  counter-balance  the  anterior 
effort,  the  sacro-lumbalis  and  longissimus  dorsi  muscles  pull  for- 
cibly upon  the  two  inferior  thirds  of  the  dorsal  portion  of  the 
spine,  and  thus  produce  the  convexity  W7hich  is  observed  in  the 
upper  part  of  this  region.  In  the  most  common  actions  of  life, 
most  people  use  the  right  arm  much  more  frequently  than  they 
do  the  left ;  as  in  raising  burdens,  etc.  Then,  at  the  same  time 
that  several  muscles  of  the  right  shoulder  draw  the  correspond- 
ing portion  of  the  vertebral  column  to  this  side,  those  of  the  op- 
posite side,  which  fill  the  spinal  gutters,  tend  to  approximate  the 
cervical  to  the  last  dorsal  vertebrae,  in  order  to  keep  the  central 
line  of  the  body  in  a  proper  position  ;  and  hence  that  lateral  cur- 
vature which,  previous  to  Bichat  and  Beclard,  was  attributed  to 
the  position  of  the  arch  of  the  aorta.  Let  us  now  apply  this 
mecanism  to  rachitic  curvatures,  and  we  will  readily  comprehend 
in  what  directions  they  must  most  frequently  be  inclined,  and  we 
will  better  understand  the  utility  and  importance  of  orthopedic 
means  in  these  deformities,  when  there  is  no  disorganization 
present. 

In  these  deviations,  the  spinal  canal  becomes  flattened,  but  not 
actually  diminished ;  hence  they  may  be  carried  to  an  extreme 
degree  without  compressing  the  medulla  spinalis ;  whilst  in  Pott's 
disease,  or  the  gibbosity  which  depends  upon  caries  of  one  or 


400  OF   THE    CHEST. 

more  vertebra?,  paralysis  generally  soon  manifests  itself.  In  the 
latter  case,  in  fact,  the  caries  seldom  advances  so  far  as  to  admit 
of  the  sinking  in  of  those  which  are  above  and  below,  without 
equally  affecting  the  nervous  cord,  which  is  also  occasionally 
compressed  in  the  deformed  canal  in  which  it  is  lodged.  We 
should  remark  that,  in  Pott's  disease,  the  curvature  is  more  acute 
and  almost  always  posterior,  whilst  that  which  arises  from  softness 
of  the  bones  is  more  elongated,  and  frequently  lateral. 

The  spinous  process  of  the  dorsal  vertebrae,  almost  horizontal  at 
first, are  inclined  and  very  much  imbricated  in  the  middle,  and  again 
become  horizontal  in  the  lower  part  of  the  back;  so  that  superi- 
orly and  inferiorly,  the  movements  of  extension  may  be  carried 
pretty  far ;  whilst  in  the  middle  portion,  they  must  be  extremely 
limited.  The  plates  (lamince)  are  short,  very  thick  and  overlap 
each  other,  so  as  to  render  it  almost  impossible  for  instruments 
to  penetrate  into  the  vertebral  canal.  The  articular  facets, 
which  are  very  oblique  and  almost  perpendicular,  even  below, 
are  so  disposed  that  the  inferior,  placed  behind  the  superior,  look 
forwards  and  outwards,  and  very  powerfully  resist  luxations 
without  fracture,  but  nevertheless  admit  of  distinct  flexion,  whilst 
they  oppose  the  movement  of  extension.  The  transverse  pro- 
cesses are  remarkable  for  their  thickness,  their  length,  and  espe- 
cially for  their  inclination  backwards;  which  disposition  in- 
creases the  depth  of  the  vertebral  gutters  externally,  and  of  the 
thoracic  excavations  within  the  chest.  The  spinal  canal  is  nar- 
row, almost  cylindrical.  The  medulla  spinalis  here  sends  off' 
nerves  to  the  thoracic  and  abdominal  parietes,  to  the  inferior 
extremities,  and  one  branch  only  of  the  brachial  plexus ;  so  that 
a  wound  of  this  cord,  between  the  second  and  third  dorsal  ver- 
tebrae, would  not  paralyze  the  superior  extremities,  and  that,  in 
order  to  suspend  the  nervous  action  in  the  inferior,  it  would  be 
necessary  for  the  lesion  to  take  place  towards  the  seventh  or 
eighth,  because  the  roots  of  the  nerves  pass  towards  the  holes  of 
conjunction  (trous  de  conjugaison)  by  following  a  line  which  is 
more  oblique  in  proportion  as  they  are  more  inferior.  The  re- 
searches of  modern  physiologists  have  demonstrated,  that,  by 
destroying  the  spinal  marrow  in  the  dorsal  region,  the  move- 
ments of  the  heart  would  be  supended,  on  account  of  the  roots 
of  the  great  sympathetic,  at  the  same  time  that  it  would  pro- 


OF   THE    CHEST.  401 

duce  paralysis ;  but  we  have  related  facts*  which  tend  to  prove 
that  these  laws  are  liable  to  some  exceptions.  Some  appropri- 
ate experiments  performed  by  Shaw,  Ch.  Bell,  M.  Magendie, 
Beclard,  M.  Descot ;  certain  observations  on  pathological  anat- 
omy related  by  several  authors,  and  those  which  we  have  re- 
corded in  the  Archives  generates  de  Medecine,  tend  to  prove  that 
the  posterior  columns  of  the  spinal  marrow  preside  over  sensi- 
bility, whilst  the  anterior  appertain  to  motion :  it  is  evident  then, 
that  one  or  the  other  of  these  two  faculties  of  relation  will  be 
impaired  the  first,  according  as  the  wound  or  disease  shall  have 
primitively  existed  either  anteriorly  or  posteriorly,  in  the  dorsal 
and  cervical  portions  of  the  spinal  column. 

From  the  strength  of  the  super-spinal,  interspinal,  yellow,  pre- 
vertebral  and  posterior  vertebral  ligaments,  and  especially  that 
of  the  intervertebral  fibro-cartilage,  together  with  the  disposition 
of  the  osseous  surfaces,  luxations  of  the  dorsal  vertebrae  must 
be  almost  impossible ;  for  the  same  reason,  their  fractures  are 
both  very  difficult  and  very  unfrequent,  and  also  because  the  soft 
parts  and  ribs  deaden  the  force  of  external  powers  which  might 
act  directly  upon  the  vertebra. 

The  curvature  of  the  ribs  is  also  very  great  here,  but  it  varies 
according  to  age  and  in  different  individuals.  In  children  it  is 
proportionately  much  less  than  in  adults :  therefore  in  the  first 
years  of  life  the  chest  appears  compressed  laterally,  whilst  it  is 
more  prominent  anteriorly  and  posteriorly.  When  this  disposi- 
tion persists  in  the  adult,  the  scapulae  usually  project  more  behind, 
constituting  what  is  called  the  "  chicken  breast" :  in  this  case  the 
ribs  appear  to  be  less  curved  under  the  shoulders,  whereby  the 
lungs  must  be  pushed  forwards,  so  that  it  has  been  supposed  that 
this  conformation  predisposed  to  tubercular  phthisis  :  a  circum- 
stance which  would  favour  the  idea  that  this  disease  is  in  a  mea- 
sure caused  by  irritation  and  inflammation. 

As  the  ribs  are  applied  upon  the  whole  extent  of  the  anterior 
surface  of  the  transverse  processes,  we  do  not  conceive  that 
their  posterior  extremity  can  be  luxated,  notwithstanding  the  as- 
sertion of  Buttet  in  the  Memoires  dc  Vacademie  royale  de  chi- 
rurgie.  If  they  were  driven  with  sufficient  force  from  before 

*  Archives  generates  de  M6decine  Janvier  et  Fevrier  1825. 

51 


402 


OF    THE    CHEST. 


backwards,  they  would  be  fractured  towards  their  angle  before 
the  costo-vertebral  and  inter-transverse  ligaments  could  be  bro- 
ken. If  the  force  acted  behind,  the  strength  of  the  costo-trans- 
verse  ligament  and  the  manner  in  which  the  head  of  the  rib  is 
supported  upon  the  bodies  of  the  vertebra?,  would  also  render 
its  fracture  more  easy  than  its  luxation.  Finally,  we  do  not 
know  of  an  authentic  example  of  this  form  of  displacement, 
and  that  related  by  Buttet  is  not  of  such  a  nature  to  produce 
conviction. 

The  intercostal  spaces  are  narrow  in  the  dorsal  region,  and  the 
more  so  as  we  approximate  the  vertebra.  Even  if  there  was 
no  other  reason  to  prevent  it,  we  should  never  perform  the  opera- 
tion for  empyema  in  the  dorsal  region.  But  there  are  other 
motives  which  should  deter  the  surgeon  from  it :  first,  because 
the  operation  would  be  rendered  difficult  by  the  thickness  of  the 
soft  parts  which  it  would  be  necessary  to  traverse  ;  and,  in  the 
second  place,  because  the  intercostal  artery  and  nerves  there 
present  their  greatest  volume,  and,  not  being  sheltered  by  the 
rib,  would  render  it  very  dangerous.  As  all  the  ribs  are  not 
supported  by  the  sternum  ;  as  the  last  five  are  but  loosely  united 
to  each  other  anteriorly,  it  follows  that  the  superior  are  more 
easily  fractured  than  the  inferior.  But  fractures  from  a  direct 
cause  are  uncommon  in  this  region,  on  account  of  the  thick  mus- 
cular layer  which  covers  the  bones  behind ;  neither  are  those  by 
contre-coup  very  common,  because,  notwithstanding  the  great 
curvature  of  the  angle,  the  rib  more  frequently  breaks  anteriorly, 
as  it  is  much  thinner  in  this  situation  and  less  firmly  supported 
than  posteriorly. 

Before  concluding,  we  must  note  that  there  is  sometimes  an 
additional  rib  on  each  side ;  in  which  case  there  are  thirteen  ver- 
tebrae. This  anomaly  is  sometimes  observed  at  the  superior,  at 
others,  in  the  inferior  part.  In  the  first  case,  the  cervical  region 
loses  its  last  vertebra,  the  costiforme  prolongation  of  which  con- 
stitutes the  supernumerary  rib  ;  in  the  latter,  it  is  the  first  lumbar 
vertebra  which  undergoes  a  similar  deviation. 

If  we  take  up  the  parts  which  have  just  been  examined,  from 
the  surface  towards  the  interior  of  the  thorax,  we  will  find  them 
arranged  in  the  following  order:  1st.  the  skin  ;  2d.  the  subcuta- 
neous layer ;  3d.  the  fibro-cellular  sheets,  which  reunite  below, 


OF    THE    CHEST.  403 

lo  form  the  aponeurosis,  and  which  include  the  trapezius,  latissi- 
mus  dorsi,  rhoniboidei,  and  serrati  postici  muscles ;  4th.  the 
deep-seated  muscles;  5th.  the  vertebrae,  ribs,  the  intercostal 
muscles,  and  the  arteries  and  nerves  of  the  same  name. 


Sect.  3.  Costal  Region. 

The  lateral  region  of  the  thorax  is  double,  and  may  be  divided 
into  two  portions  on  each  side :  one  superior,  which  enters  into 
the  axillary  region,  and  which  has  already  been  examined ;  the 
other,  inferior,  or  sub-axillary,  wrhich  forms  the  costal  region, 
properly  so  called.  Of  the  first,  which  was  described  in  its 
place,  we  will  only  speak  in  an  accessory  manner  in  this  section. 

The  costal  region  is  bounded,  superiorly,  by  a  line  drawn  from 
the  inferior  angle  of  the  scapula,  along  the  hollow  of  the  axilla, 
below  the  nipples ;  inferiorly,  by  another  line,  carried  along  the 
margin  of  the  costal  cartilages,  and  thus  uniting  the  two  scapulo- 
coxal  and  clavi-coxal  lines  ;  anteriorly  by  the  sternal  region,  and 
posteriorly  by  the  dorsal.  Upon  its  surface  we  observe,  above,  the 
prolongation  of  the  two  borders  of  the  axilla,  and,  in  their  interval, 
the  great  excavation  which  forms  the  commencement  of  the  cav- 
ity of  this  region.  The  first  prominence  supports,  anteriorly,  a  por- 
tion of  the  mammary  gland,  below  which  we  see  a  depression, 
which  we  would  call,  with  M.  Gerdy,  the  sub-mammary  degression; 
the  other  descends  obliquely  backwards,  and  may  be  distinguished 
even  as  far  as  the  last  ribs.  In  strong  muscular  subjects,  we  no- 
tice, between  the  two  preceding  prominences,  some  digital  impres- 
sions, which  indicate  the  origins  of  the  serratus  anticus.  Finally, 
we  perceive  by  the  touch,  unless  the  subjects  are  very  fat,  the 
ribs,  intercostal  spaces,  and  the  summits  of  the  twelfth  and 
eleventh  ribs,  when  they  are  free  in  the  muscular  parietes. 

CONSTITUENT   PARTS. 

i.  The  Skin. 

It  is  destitute  of  hairs  and  wrinkles,  but  contains  a  great  num- 
ber of  sebaceous  follicles,  which  give  it  a  rugous  and  uneven  as- 
pect. Posteriorly,  it  is  of  considerable  thickness  :  anteriorly,  it, 


101  OF    THE    CHEST, 

is  more  attenuated,  and  its  characters  are  a  mixture  of  those  ot 
the  skin  of  the  dorsal,  abdominal,  and  sternal  regions.  It  is  less 
adherent  to  the  subjacent  tissues  than  in  the  dorsal  region,  moves 
readily  over  them,  and  is  very  extensible  ;  therefore,  its  wounds, 
with  loss  of  substance,  are  easily  and  promptly  united.  This 
species  of  mobility  is  very  serviceable  in  the  operation  for  em- 
pyema  or  paracentesis  thoracis,  as  we  are  thereby  enabled  to 
prevent  the  admission  of  air  into  this  cavity. 

ii.  Tlie,  Subcutaneous  Layer. 

In  emaciated  individuals  it  is  thin,  yet  very  distinct  and  lamel- 
lated  :  sometimes,  on  the  contrary,  its  thickness  is  so  considerable 
as  to  prevent  us  distinguishing  the  intercostal  spaces  through  the 
skin.  This  layer  is  prolonged,  on  the  one  hand,  between  the 
pectoralis  major  muscle  and  the  ribs  ;  and,  on  the  other,  before 
the  latissimus  dorsi,  in  order  to  penetrate  the  hollow  of  the  axilla. 
It  encloses  arterial  and  venous  twigs,  and  nervous  ramifications. 
The  adipose  vesicles  which  are  situated  in  its  external  laminae, 
are  generally  elongated,  reddish,  and  flattened,  in  persons  who 
have  lost  their  embonpoint. 

in.   The  Aponeurosis. 

This  fascia  is  also  very  thin,  and  rather  cellular  than  fibrous  ; 
at  first,  it  is  pretty  strongly  marked  upon  the  external  surface  of 
the  obliquus  externus  muscle,  where  it  is  continuous  with  the 
aponeuroses  of  the  belly  ;  it  ascends,  single  and  attenuated,  upon 
the  serratus  magnus,  as  far  as  the  axillary  excavation  ;  after- 
wards, it  applies  itself,  anteriorly  and  posteriorly,  upon  the  deep 
surface  of  the  great  pectoral  and  dorsal  muscles,  in  order  to  en- 
velope their  margin  and  thus  pass  upon  the  arm. 

iv.  The  Muscles. 

There  are  some  which  are  only  applied  upon  the  ribs,  and 
which  we  must  first  examine.  Anteriorly,  we  find  a  small  por- 
tion of  the  pectoralis  major,  when  it  descends  upon  the  sixth  and 
seventh  ribs  ;.  posteriorly,  the  most  important  part  of  the  latissi- 


OP    THE    CHEST. 

mus  dorsi ;  this  last  is  disposed  in  such  a  manner,  that  its  costal 
digitations  pass  almost  directly  to  the  inferior  angle  of  the  scapula, 
and  that  inserted  into  the  humerus,  it  may  depress  the  arm  or 
elevate  the  last  four  ribs ;  for  the  same  reason,  when  the  latter 
bones  are  fractured,  it  tends  to  draw  the  fragment  to  which  it  is 
attached,  upwards  and  outwards ;  consequently,  it  is  an  inspi- 
rator, since  it  may  dilate  the  thorax :  therefore,  during  exertions 
and  in  deep  inspirations,  the  arms  are  raised  almost  instinctively, 
seeking  to  fix  themselves  in  a  more  or  less  solid  manner  upon 
surrounding  bodies.  Inferiorly  and  anteriorly,  we  meet  with  the 
digitations  of  the  external  oblique,  which  originate  from  the 
last  seven  ribs,  where  they  intersect  those  of  the  preceding,  and 
especially  the  digitations  of  the  serratus  magnus ;  all  these  fleshy 
tongues  cover  about  an  inch  and  a  half  of  the  osseous  portion  of 
the  ribs ;  they  are  oblique  forwards,  downwards,  and  inwards. 
According  to  their  arrangement,  the  obliquus  descendens  is  one 
of  the  most  powerful  depressors  of  the  ribs,  and  it  cannot  draw 
upwards  the  pelvis,  or  stretch  the  aponeurosis  of  the  abdomen, 
until  the  other  muscles  have  previously  fixed  the  thorax.  In  the 
space  circumscribed  by  the  three  preceding  muscles,  we  observe 
the  inferior  digitations  of  the  serratus  anticus,  the  direction  of 
which  is  nearly  parallel  to  that  of  the  ribs.  The  last  of  these 
digitations,  in  abandoning  the  scapular  angle,  leaves  between  it 
and  the  rhomboideus  and  latissimus  dorsi  muscles,  a  space,  a 
kind  of  opening,  mentioned  already  when  on  the  dorsal  region, 
which  leads  between  the  shoulder  and  the  thorax,  and  which 
forms  a  communication  between  the  subcutaneous  cellular  tissue 
of  the  costal  region  and  the  deep  layers  of  the  supra-clavicular 
and  dorsal  regions;  a  space,  finally,  through  which  the  pus, 
which  may  have  formed  upon  the  lateral  parts  of  the  neck,  might 
gravitate,  and  form  an  abscess  in  the  lower  part  of  the  costal 
region,  after  having  passed  under  the  shoulder.  In  the  last  place, 
we  see  the  trapezius  and  serratus  posticus  inferior,  the  latter 
placed  under  the  latissimus  dorsi,  and  which  cover  only  a  very 
small  portion  of  the  costal  region. 

The  other  muscles  of  the  side  of  the  chest  are  enclosed  in  the 
intercostal  spaces,  and  form  two  planes  which  intersect  each  oth- 
er at  almost  right  angles  :  the  extenial  is  oblique  downwards  and 
forwards ;  the  internal,  on  the  contrary,  descends  backwards,  and 


406  OF   THE    CHEST. 

it  is  upon  this  disposition  that  Hamberger  founded  his  opinion 
that  the  former  was  an  expirator  and  the  latter  an  inspirator  ;  a 
cellular  layer,  in  which  we  sometimes  observe  adipose  vesicles, 
separates  the  two,  and  it  is  between  this  layer  and  the  internal  in- 
tercostal muscle  that  the  artery,  veins  and  nerves  of  the  same 
name  are  found  ;  internally,  their  fibres  may  be  distinguished 
through  the  transparent  pleura,  which  is  separated  from  them  by 
some  rare  and  lamellated  cellular  tissue,  in  which  adipose  clus- 
ters are  sometimes  developed  in  such  a  manner  as  to  repel  this 
membrane  inwards,  and  thereby  produce  those  free  and  floating 
appendices  which  are  observed  in  certain  old  men,  upon  its  inner 
surface  ;  externally  a  thin  fibrous  web,  which  passes  from  the 
external  surface  of  one  rib  to  the  other,  separates  them  from  the 
superficial  muscles,  and  seems  to  be  blended  with  the  fibrous 
bundles  which  are  naturally  mingled  with  the  fleshy  fibres.  These 
two  muscular  planes  exist  throughout  the  whole  extent  of  the  cos* 
tal  region,  whilst  the  external  alone  is  found  in  the  dorsal,  and  the 
internal  in  the  sternal  region. 

v.  The  Arteries. 

The  Intercostal  is  the  only  one  which  deserves  much  attention 
on  account  of  its  size  and  position,  relatively  to  the  operation  of 
empyema,  on  the  one  part,  and  to  penetrating  wounds  of  the 
chest,  on  the  other.  This  artery  is  situated  between  the  internal 
intercostal  muscle  and  the  cellular  layer  which  separates  it  from 
the  external,  and  runs  to  place  itself  in  the  groove  of  the  inferior 
border  of  the  rib,  just  where  that  curvature  commences  which 
forms  the  angle  of  this  bone  ;  it  passes  to  the  extent  of  some  in- 
ches thus  enclosed  in  a  canal,  which  is  muscular  internally,  and 
osseous  posteriorly  or  externally  ;  so  that  we  might,  if  I  may 
so  say,  shave  the  rib,  as  far  as  the  middle  of  the  side  of  the  chest, 
without  wounding  the  artery ;  but  then  this  vessel  becomes  more 
and  more  isolated,  and  finally  places  itself  completely  under  the 
margin  of  this  bone  ;  as  it  advances  farther  towards  the  sternal 
region,  it  loses  much  of  its  volume,  and  inosculates  with  the  ex- 
ternal branches  of  the  internal  mammary  artery.  The  intercos- 
tal artery,  in  its  course,  gives  oft'  a  great  many  branches,  which 
meet  upon  the  external  surface  of  the  corresponding  rib.  and  . 


OP   THE    CHEST.  407 

which  traverse  the  deep  muscles  in  order  to  ramify  in  the  su- 
perficial :  but  there  is  only  one  among  these  branches  worthy  of 
notice ;  it  is  that  which  separates  from  the  trunk  towards  the  mid- 
dle of  the  space,  and  which  runs  obliquely  forwards  to  the  superior 
border  of  the  rib  below,  in  order  to  reach  the  external  muscles. 
Its  point  of  origin  is  so  variable  that  we  are  not  always  sure  of 
avoiding  it  in  paracentesis  thoracis ;  but  fortunately  it  is  seldom  so 
large  as  to  give  rise  to  a  dangerous  hcetnorrhage.  In  general,  the 
trunk  of  the  intercostal  artery  lies  much  nearer  the  pleura  than 
to  the  superficial  muscles  of  the  thorax,  and  is  more  easily  wound- 
ed the  nearer  we  approach  the  anterior  region  ;  therefore,  in  or- 
der to  avoid  this  accident,  it  is  customary  to  penetrate  the  thorax, 
in  operations,  by  cutting  before  the  angle  of  the  ribs.  We  should 
also,  in  these  operations,  be  careful  to  divide  the  tissues  nearer  the 
inferior  than  the  superior  rib,  and  remember  that,  in  certain  dis- 
eases, the  secondary  branches  acquire  double  and  even  triple  their 
ordinary  dimensions. 

It  follows  then  from  the  position  of  these  arteries  that  they 
may  be  divided  in  the  operation  for  empyema,  by  simple  punc- 
ture, penetrating  wounds,  and  in  the  evacuation  of  an  internal  col- 
lection, an  abscess  of  the  liver,  for  example  ;  finally  by  fragments 
or  spiculse  of  fractured  ribs.  In  all  these  cases,  let  there  be  a 
wound  or  not,  it  would  be  almost  impossible  to  seize  the  vessel 
with  the  forceps  and  tie  it ;  from  without,  we  cannot  compress  it, 
and  therefore  the  blood  which  is  almost  constantly  extravasated 
into  the  chest,  instead  of  escaping  externally,  soon  gives  rise  to 
alarming  symptoms.  Now  it  is  evident  that  the  thread  passed  by 
Gerard  around  the  rib,  by  means  of  a  curved  needle,  in  order  to 
embrace  the  artery,  or  by  Goulard  with  his  needle  having  a  long 
handle  and  perforated  near  its  point,  should  be  rejected  ;  on  the 
one  hand,  because  it  exacts  a  double  wound,  on  the  other,  because 
the  artery  would  aot  be  completely  flattened  by  it  in  the  groove 
of  the  rib  ;  finally,  because  acting  upon  one  extremity  only  of  the 
divided  vessel,  the  hemorrhage  might  continue  from  the  other. 
The  jeton  of  Quaisnay,  the  plaque  of  Lottery,  the  complicated 
machine  of  Bellocq,  \vould  be  still  less  certain  ;  and  all  these 
means  would  be  advantageously  replaced  by  those  which  have 
been  recommended  by  Desault  and  Sabatier.  After  having  in- 
troduced through  the  wound,  into  the  thorax,  a  small  empty  sac, 


408  OF   THE    (JHEST. 

made  of  linen,  oiled  silk,  or  a  portion  of  bladder,  which  should  be 
retained  externally  by  threads,  it  would  be  easy  to  fill  it  with  lint 
or  any  other  substance,  and  thereby  give  it  such  a  size  as  will  pre- 
vent its  escape  through  the  intercostal  space.  By  this  means  the 
compression  will  act  upon  the  two  divided  extremities  of  the  ar- 
tery at  the  same  time,  in  a  certain  and  exact  manner,  without 
much  inconvenience  to  the  patient. 

The  other  arteries  of  the  costal  region,  are,  for  the  most  part, 
twigs  of  the  preceding,  which  anastomose,  superiorly  and  anteri- 
orly, with  the  sub-scapularis  or  external  mammary ;  superiorly 
and  posteriorly,  with  the  scapular  branch  of  the  cervicalis  de- 
scendens.  All  these  branches  ramify  in  the  superficial  muscles, 
the  cellular  layers  and  the  skin  ;  they  are  but  small,  however,  in 
the  healthy  state,  and  are  not  of  actual  importance  in  surgery, 
except  by  forming  chains  of  communication  between  different 
remote  parts  of  the  body. 

vi.  The  Veins. 

These  vessels  are  disposed  exactly  in  the  same  manner  as  the 
arteries. 

vii.  The  Lymphatics. 

They  form  two  series,  which  follow  two  different  directions. 
The  superficial  set  ascends  to  the  glands  of  the  axilla,  whilst  the 
deep  seated,  following  the  course  of  the  bloodvessels,  run  from 
the  intercostal  spaces  upon  the  sides  of  the  vertebrae,  or  into  the 
glands  situated  in  the  anterior  and  posterior  mediastinal  spaces : 
whence  it  follows  that  diseases  of  the  skin  or  of  the  superficial 
layer  frequently  produce  affections  of  the  axillary  lymphatic 
glands,  without  acting  upon  those  in  the  cavity  of  the  thorax : 
whilst  the  latter  frequently  participate  in  deep  seated  maladies. 
A  blister,  for  example,  applied  upon  the  costal  region,  will  occa- 
sion pain  and  tumefaction  in  the  axilla ;  a  sarcoma,  or  caries  of 
the  ribs,  on  the  contrary,  will  re-act  behind  the  sternum  or  before 
the  spine. 


OF   TUB    CHEST.  409 


vin.  The  Nerves. 

The  serratus  magnus  anticus  muscle  derives  its  nerve  from  the 
fourth  and  fifth  cervical  pairs,  and  might,  consequently,  preserve 
its  action  although  the  spinal  marrow  had  been  divided  in  the 
upper  purt  of  the  dorsal  region.  Some  filaments  are  also  sent 
off  from  the  brachial  plexus  to  the  latissimus  dorsi  and  pectoralis 
major  ;  but  the  nerves  proper  to  this  region  are  the  intercostals, 
each  of  which  is  nearly  of  equal  volume  with  the  artery  of  the 
same  name,  follows  the  same  direction,  is  situated  below  and  in 
contact  with  it,  and  divides  in  the  same  manner ;  so  that  the 
opening  of  the  vessel  alone,  almost  certainly  indicates  the  divis- 
ion of  the  nerve.  However,  these  nerves  descend  farther  than 
the  artery  into  the  space  filled  by  the  muscles,  and  soon  cross  the 
internal  surface  of  the  inferior  rib.  The  last  especially,  which 
some  persons  have  considered  as  the  first  lumbar  branch,  soon 
deviates  from  the  osseous  arch,  in  order  to  pass  into  the  interval 
of  the  muscular  layers  of  the  abdominal  parietes. 

ix.  The  Skeleton. 

It  is  formed  by  the  bodies  of  the  last  seven  ribs,  and  is  remark- 
able for  the  disposition  of  these  bones  and  their  relations  with  th6 
circumjacent  organs.  We  have  just  seen  that  the  ribs  were  cov- 
ered externally  by  large  muscles  ;  that  their  margins  were  fixed 
by  others,  and  lodged  the  principal  vessels  and  nerves,  and  that 
internally  they  were  lined  by  the  pleura  only.  It  must  therefore 
follow  from  this  arrangement  that  their  fractures,  whether  pro- 
duced by  a  force  which  tends  to  increase  the  curvature  of  these 
bones,  or  to  diminish  it,  will  be  attended  with  displacements  and 
symptoms  more  or  less  serious,  according  to  the  situation  of  the 
solution  of  their  continuity.  Thus,  does  the  fracture  exist  in  the 
course  of  the  curved  line  from  which  the  serratus  magnus  origin- 
ates? this  muscle  will  draw  the  posterior  fragment  outwards,  up- 
wards and  backwards,  whilst  the  obliquus  descendens  will  carry 
the  anterior  fragment  of  the  bone  in  the  opposite  direction.  Is 
the  fracture  situated  further  backwards  and  upwards  ?  then  the 
latissimus  dorsi  and  serratus  anticus  will  act  upon  the  anterior 

52 


410  OF   THE    CHEST. 

fragment,  will  tend  to  make  it  ride  over  the  posterior,  and  the  dis- 
placement, in  relation  to  length,  will  be  considerable.  If  the  ribs 
are  broken  nearer  their  anterior  extremity,  the  over-lapping  will 
be  more  difficult,  because  at  the  same  time  that  the  serratus  mag- 
nus  tends  to  draw  one  of  the  portions  outwards,  and  that  the 
other  is  drawn  by  the  pectoralis  major  in  the  same  direction,  the 
obliqui,  transversalis  and  diaphragm  act  upon  the  latter,  in  order 
to  draw  it  downwards  and  inwards.  However,  as  most  of  these 
muscles  are  at  the  same  time  attached  over  a  pretty  great  extent 
of  the  external  surface  of  the  ribs,  it  is  seldom  that  the  displace- 
ment can  be  carried  very  far ;  more  especially  as  the  sternum,  on 
the  one  hand,  and  the  spine  on  the  other,  equally  oppose  it,  in 
maintaining,  by  means  of  the  sound  ribs,  the  fragments  in  a  posi- 
tion which  can  scarcely  deviate  from  the  natural  state.  It  is  not 
in  this  way  then  that  fractures  of  the  ribs  become  dangerous, 
but  from  the  nature  of  the  organs  which  have  been  wounded  at 
the  same  time,  and  the  derangement  of  function  consequent 
thereto.  In  fact,  if  this  fracture  is  direct,  the  pleura,  lungs,  as  well 
as  the  intercostal  vessels  and  nerves,  will  generally  be  stretched, 
even  torn,  and  hence  extravasations,  inflammations  of  the  chest, 
etc.  If,  on  the  contrary,  it  is  produced  by  a  counter-stroke,  the 
fragments  will  have  lacerated  more  or  less  the  external  soft  parts, 
likewise  the  vessels,  nerves  and  pleura ;  then  we  may  expect  in- 
flammations, abscesses,  and  pains  increased  especially  by  the  res- 
piratory movements.  Finally,  if  the  fracture  is  comminuted,  if 
spiculae  are  detached,  as  frequently  happens,  these  osseous  points 
will  wound  the  lungs  the  intercostal  artery,  or  the  external 
organs,  or  all  these  parts  simultaneously,  and  will  in  all  cases  act 
as  foreign  bodies. 

As  the  true  ribs  become  much  shorter  and  less  flexible  as  they 
ascend,  it  is  evident  that  those  which  are  most  superior  would  be 
most  readily  fractured,  if,  on  the  other  hand,  the  shoulder,  the 
arm,  and  the  muscles,  did  not  protect  them  very  efficaciously 
above,  in  the  whole  axillary  portion,  whilst  inferiorly,  or  in  the 
costal  regions,  properly  so  called,  they  are  almost  uncovered,  and 
much  more  exposed  to  external  violence.  When  one  rib  only  is 
broken,  which  is  unusual,  as  the  displacement  can  only  be  pro- 
duced by  the  same  impulse  which  fractured  the  bone,  it  always 
takes  place  inwards ;  these  isolated  fractures  are  most  frequently 


OP    THE    CHEST.  411 

produced  by  balls  or  other  projectiles  propelled  by  gunpowder ; 
their  frequency,  however,  is  not  proportionate  to  that  of  wounds 
of  this  species,  and  for  these  reasons ; — if  the  vulnerant  body 
strikes  near  one  of  the  borders  of  a  rib,  it  will  glance  and  tra- 
verse the  intercostal  space  and  chest ;  if,  on  the  contrary,  it  is 
driven  against  the  middle  of  the  external  surface  of  the  bone,  as 
the  latter  may  yield  and  spring  back,  the  foreign  body  will  still 
be  turned  aside,  and  in  this  case  it  will  plough  through  the  tho- 
racic parietes  from  before  backwards,  or  from  behind  forwards, 
without  producing  fracture  or  penetrating  into  the  pectoral 
cavity.  In  the  lateral  region  of  the  thorax,  the  ribs  are  more  flat- 
tened, and  those  which  are  most  superior  are  so  solidly  fixed,  that 
a  knife,  sword,  etc.,  might  pass  along  one  of  these  bones,  in  the 
direction  of  its  length,  without  fracturing  it,  or,  at  least,  merely 
detaching  some  scales,  and,  again,  in  such  a  manner  that  the  point 
of  the  instrument  may  be  broken  off  and  left  in  the  body  of 
the  rib,  projecting  into  the  chest.  Such  a  case,  an  instance  of 
which  came  under  the  care  of  Gerard,  would  be  somewhat  em- 
barrassing, especially  if  the  weapon  was  broken  off  so  near  the 
osseous  surface  that  it  could  not  be  taken  hold  of  externally ; 
then  the  means  employed  by  this  surgeon,  that  is  to  say,  a  steel 
thimble  placed  upon  the  finger  and  introduced  through  the  inter- 
costal space  into  the  chest,  in  order  to  press  the  point  of  the 
weapon  outwards,  is  the  only  one  which  \vould  afford  any  chance 
of  success. 

The  intercostal  spaces  must  now  be  examined.  They  gen- 
erally differ  in  breadth :  the  third  is  the  broadest  of  all ;  the 
first  and  second  follow  next;  the  fourth,  fifth,  sixth,  and  seventh, 
differ  but  little  from  each  other ;  the  last  two  are  broader,  but  of 
less  importance.  It  should  be  noted,  that  this  difference  in  the 
breadth  of  the  spaces  which  separate  the  ribs,  is  most  evident  in 
the  anterior  half  of  the  chest,  and  that  this  gradual  enlargement, 
which  we  observe  from  behind  forwards,  arises  from  the  descent 
which  the  bones  make  at  first,  in  order  to  ascend  afterwards. 
This  peculiarity  merits  some  attention  in  surgery,  because  it  ren- 
ders the  operation  of  empyema  more  easy  before  the  angle  of 
the  ribs,  than  at  the  posterior  part  of  this  curvature.  However, 
it  is  at  the  union  of  the  two  anterior  thirds  with  the  posterior 
third  of  a  line  drawn  from  the  sternum  to  the  spine,  that  we  are 


*>F   THE    CHEST. 

recommended  to  penetrate  into  the  chest  for  the  purpose  of 
evacuating  fluids.  In  giving  this  advice,  surgeons  supposed  that 
the  artery,  which  is  there  concealed  by  the  rib,  was  less  in  dan- 
ger, and  that  the  fluid  would  flow  out  easier ;  but  we  will  per- 
ceive directly,  that  these  data  deserve  further  investigation. 

There  enters  into  each  intercostal  space,  1st,  the  two  intercos- 
tal muscles  ;  2d,  two  cellular  layers ;  3d,  the  intercostal  artery 
and  vein  ;  4th,  the  nerve  of  the  same  name.  The  inferior  mar- 
gin of  the  superior  rib  limits  it  above.  Thin  and  excavated  inter- 
nally, forming  a  groove,  which  disappears  anteriorly,  where  this 
part  of  the  rib  is  rounded,  this  margin,  considered  in  its  ensemble. 
is  convex  outwards  and  downwards.  The  superior  border  of 
the  inferior  rib  is  thick,  obtuse,  concave  throughout  its  whole  ex- 
tent, and  its  direction  is  that  which  we  ought  to  follow,  when  we 
traverse  one  of  the  intercostal  spaces. 

Now  the  operation  of  empyema  may  be  the  object  of  several 
anatomical  remarks.  Thus,  although  we  might  perform  it  indis- 
criminately upon  all  of  the  intercostal  spaces,  and  in  every  point 
of  their  extent,  yet,  unless  from  absolute  necessity,  we  only  do  it 
upon  some  one  of  them,  and  upon  one  part  in  preference  to  anoth- 
er. We  do  not  operate,  for  example,  upon  the  five  or  six  supe- 
rior, because  they  are  covered  by  the  shoulder  and  the  pectoralis 
major  muscle  ;  besides,  extravasated  fluids  do  not  accumulate  in 
the  upper  part  of  the  thorax ;  we  do  not  operate  upon  the  last 
two,  because,  the  diaphragm  which  naturally  rises  up  against  their 
internal  surface,  might  be  divided  and  thereby  allow  the  instru- 
ment to  penetrate  into  the  cavity  of  the  peritoneum  ;  neither  do 
we  select  the  anterior  third  of  these  spaces,  notwithstanding  they 
are  broader  in  this  portion  ;  in  the  first  place,  because  it  is  diffi- 
cult to  avoid  the  arteries,  next  because  the  matters  are  usually 
collected  more  posteriorly,  and  especially  because  we  cannot  ren- 
der this  part  the  most  dependent.  Finally,  we  should  not  per- 
form the  operation  for  empyema  at  the  posterior  part,  as  it  would 
then  be  necessary  to  cut  transversely,  sometimes  the  trapezius  or 
serratus  posticus  inferior,  and  always  the  latissimus  dorsi ;  because 
also  the  space  is  narrower,  and  the  vessels  and  nerves  are  not  so 
well  protected  by  the  rib.  From  what  has  preceded  we  con- 
ceive, that,  in  order  to  give  issue  to  liquids  collected  in  the  tho- 
rax, it  will  be  necessary  to  penetrate  into  this  cavity,  anterior  to 


OF   THE    CHEST. 

the  latissimus  dorsi,  and,  for  this  purpose,  we  can  only  select  a  point 
between  the  hollow  of  the  axilla  and  the  last  intercostal  space  but 
one.     It  is  between  the  second  and  third  ribs,  counting  from  be- 
low upwards,  that  Verduc  and  some  other  surgeons  have  advised 
makingthe  opening,  on  either  side,  because  this  space  corresponds 
to  the  point  which  is  best  adapted  for  the  discharge  of  the  pus ; 
but  as  the  diaphragm  is  pushed  up  by  the  spleen  on  the  left,  and 
by  the  liver  on  the  right,  we  prefer  operating  upon  the  third  space, 
as  recommended  by  Dionis,  Garengeot,  Le  Dran,  Bertrandi ;  or 
upon  the  fourth,  according  to  the  advice  of  Subatier,  MM.  Boyer, 
Richerand,  etc.  If  we  select  the  right  side,  it  will  be  imprudent  to 
operate  lower  down,  not  only  because  the  diaphragm  rises  dur- 
ing expiration,  but  also  because  this  organ  may  contract  adhesions 
with  the  thoracic  parietes,  in  which  case  it  might  be  readily  trans- 
fixed and  the  instrument  enter  the  belly.  M.  Laennec  was  witness 
to  an  accident  of  this  kind.     On  the  other  hand,  this  professor  has 
remarked  that  the  diaphragm  sometimes  ascends  to  a  level  with 
the  sixth  and  even  the  fifth  true  rib  ;  wherefore,  he  thinks  tiiat  it 
would  generally  be  more  proper  to  perform  the  operation  for  em- 
pyema  in  the  middle  of  the  chest ;  especially  as  in  females,  and 
even  in  many  males,  this  point  is  actually  the   most  dependent 
when  the  patient  lies  horizontally  and  a  little  upon  the  side.     It  is 
for  the  same  reason  that  Samuel  Cooper*  recommends  the  incis- 
ion to  be  made  between  the  sixth  and  seventh  true  ribs.     Be  this 
as  it  may,  it  follows  from  these  different  opinions,  that  the  place 
of  election  for  paracentesis  thoracis  is  not  yet  well  determined, 
and  that  we  may  perform  it,  with  nearly  equal  advantages,  upon 
the  third,  fourth,  fifth  and  sixth  intercostal  spaces  in  the  lateral 
region,  (counting  from  below).  In  either  of  these  places,  it  would 
only  be  necessary  to  divide  the  skin,  the  adipose  layer,  the  mem- 
brane of  greater  or  less  thickness  which  covers  the  muscles,  the 
external  and  internal  intercostal  muscles,  and  the  pleura.    By  fol- 
lowing the  direction  of  the  rib,  the  digitations  of  the  serratus 
magnus  and  obliquus  externus  will  only  require  to  be  separated  ; 
and  if  the  opening  is  made  immediately  before  the  latissimus  dor- 
si,  it  will  always  be  easy  to  avoid  the  artery,  since  it  is  then  en- 
tirely concealed  by  the  rib.     Surgeons  have  particularly  advised 

*Surgical  Dictionary. 


414  OF   TIIL    CHEST, 

proceeding  with  great  caution  when  dividing  the  pleura,  for  fear 
of  wounding  the  lung  ;  but  it  seems  to  us  that  there  is  very  little 
foundation  for  such  fears.  In  fact,  if  the  respiratory  organ  is  free 
from  adhesions,  the  external  air  will  promptly  repel  it,  and  drive 
it  beyond  the  reach  of  the  instrument ;  if,  on  the  contrary,  it  ad- 
heres more  or  less  intimately,  we  will  wound  it  in  spite  of  all  our 
precautions ;  and,  moreover,  what  dangers  can  result  from  wounds 
of  such  a  nature  ?  Finally,  if  we  operate  upon  the  abscess  itself, 
we  run  no  risk  at  all.  We  think  then  that  empyema,  instead  of 
being  a  delicate  operation,  might,  when  we  have  properly  ascer- 
tained the  intercostal  space,  be  reduced  to  a  simple  incision,  simi- 
lar to  that  of  opening  any  deep-seated  abscess  whatsoever. 

After  this  operation,  as  well  as  after  penetrating  wounds  of 
whatsoever  nature  they  may  be,  as  the  intercostal  muscles  are 
divided  transversely  to  the  direction  of  their  fibres,  when  they 
retract,  they  leave  an  opening  into  which  the  lung  may  insinuate 
itself  and  form  a  tumour  of  greater  or  less  volume  externally. 
The  observations  of  Schenkius,  Tulpius,  Fabricius  de  Hilden, 
and  Ruysch,  support  this  assertion.  It  may  also  happen  that  the 
external  parts  will  cicatrize,  whilst  the  intercostal  aperture  re- 
mains :  the  lung  would  then  form  a  complete  hernia  under  the 
skin,  especially  during  inspiration ;  a  remarkable  example  of 
which  is  related  by  Sabatier.  On  this  occasion,  we  may  also 
notice  another  still  more  singular,  which  was  pointed  out  to  us  by 
M.  J.  Cloquet,  whilst  dissecting  for  his  anatomical  lectures  in 
1821.  This  case  occurred  in  a  man  of  about  fifty  years,  who 
had  several  of  his  ribs  broken,  by  the  wheel  of  a  carriage,  nine 
years  previously;  the  middle  portion  of  the  fifth,  sixth,  and 
seventh  ribs  had  disappeared,  and  left  a  space  large  enough  to 
admit  the  fist ;  a  space  through  which  the  lung  protruded  and 
projected  under  the  skin,  whenever  this  man,  who  otherwise  en- 
joyed perfect  health,  inspired  or  made  any  exertion. 

Sect.  4.  Mammary  Region. 

It  is  formed  by  the  mammae,  and  cannot  have  any  exact  limits : 
in  man,  it  scarcely  exists,  and  does  not  merit  any  special  consid- 
eration ;  in  the  female,  on  the  contrary,  it  is  an  important  region, 
but  after  puberty  only ;  previous  to  this  epoch,  the  breast  is  only 


OF   THE    CHEST.  115 

rudimental,  as  it  always  is  in  the  opposite  sex.  The  volume, 
form  and  density  of  this  organ  vary  according  to  the  age  of  the 
mature  female,  her  state,  constitution,  etc.  Thus  the  mammae 
represent  two  half  spheres,  regularly  rounded  and  firm  upon  the 
fore  part  of  the  chest  of  young  virgins ;  soft,  pendent,  and  more  or 
less  flattened,  in  women  who  have  had  children.  Sometimes  they 
form  a  considerable  relief ;  at  others,  we  scarcely  distinguish  them, 
and  this  may  depend  upon  their  intrinsic  volume  or  the  abun- 
dance of  the  cellular  tissue  which  surrounds  them.  If,  on  the 
one  hand,  the  well-formed  breasts  concur  in  setting  off  the 
graces  and  elegance  of  the  sex,  if  their  functions  render  their 
preservation  of  the  highest  importance,  on  the  other  hand,  they 
sometimes  embarrass  the  surgeon  considerably,  when  it  becomes 
necessary  to  apply  an  apparatus  upon  the  thorax.  For  example, 
the  bandage  of  Desault,  in  fractures  of  the  clavicle  ;  those  which 
are  used  for  fractures  of  the  ribs ;  in  short,  all  compressive  ban- 
dages which  we  are  obliged  to  apply  around  the  thorax  of  fe- 
males, require  considerable  precaution,  on  account  of  the  mam- 
mae. These  organs  also  prevent  our  deriving  such  satisfactory 
results  in  this  point  from  percussion  and  auscultation,  whether 
mediate  or  immediate,  as  in  man. 

CONSTITUENT   PARTS. 

i.  The  Skin. 

The  skin  of  the  breast  is  delicate,  smooth,  soft  to  the  touch, 
white  or  slightly  bluish  in  the  pubescent  virgin ;  uneven,  wrinkled, 
thicker,  and  less  white,  in  those  who  have  borne  several  children, 
or  who  have  arrived  at  a  certain  age.  In  the  centre  of  the  re- 
gion, it  is  surmounted  by  the  nipple,  a  sort  of  homogeneous, 
spongy,  erectile,  extremely  sensible,  rugous,  reddish,  or  yellowish 
body,  perforated  by  a  great  many  foramina,  which  lead  to  the 
lactiferous  ducts,  surrounded  by  an  areola  of  greater  or  less 
breadth,  which  is  generally  of  a  rosy  or  livid  colour,  analagous  to 
that  of  the  nipple  itself.  Here,  this  membrane  possesses  but  a 
very  limited  extensibility,  and  encloses  a  great  number  of  seba- 
ceous follicles ;  therefore,  it  cracks  very  easily  during  lactation, 
when  it  is  irritable.  The  proper  tissue  of  the  nipple  resembles 


410  OP   THE    CHEST. 

bacon :  all  the  elements  composing  it  are  so  blended  together  that 
it  is  difficult  to  distinguish  them,  and  hence,  although  Ruysch 
affirms  that  he  has  traced  the  nervous  filaments  as  far  as  the  cu- 
taneous papillae,  it  is  doubtful  that  he  has  done  so. 
I 

ii.  The  Subcutaneous  Layer. 

This  layer  differs  from  that  of  the  preceding  regions  by  its 
thickness,  which  is  much  greater;  by  its  more  numerous  and 
larger  adipose  cells,  and  by  including  the  mammary  gland.  The 
cellular  tissue  is  rather  filamentous  than  lamellated,  and  sends  off 
many  septa,  which  are  intimately  attached  to  the  internal  surface 
of  the  skin,  and  are  prolonged  across  the  secretory  organ. 

HI.  The  Arteries. 

They  appertain  to  the  internal  mammary,  intercostals,  to  the 
anterior  thoracic,  and  especially  to  the  external  mammary  or  in- 
ferior thoracic  artery.  The  latter  is  the  largest ;  its  principal 
branches  are  found  on  the  outer  side  of  the  region,  under  the 
margin  of  the  pectoralis  major ;  these  are  the  vesssls  divided  by 
the  instrument  in  terminating  the  amputation  of  the  breast,  and 
•which  most  frequently  give  rise  to  haemorrhage  in  this  operation. 
The  branches  of  the  first  ramify  upon  the  sternal  side,  and  be- 
come more  superficial ;  the  second  supplies  the  superior  part,  and 
they  all  anastomose  with  one  another,  forming  a  plexus,  which  is 
so  disposed  that  the  extirpation  of  the  mammary  gland  would 
rarely  be  followed  by  a  dangerous  bleeding,  if  the  disease  had 
not  caused  an  augmentation  in  the  volume  of  the  arteries.  We 
must  expect,  therefore,  during  the  operation,  to  meet  with  arte- 
rial branches,  which  will  be  more  numerous  and  large  in  propor- 
tion to  the  duration  and  size  of  the  tumour.  In  all  cases,  it  must 
be  recollected  that  these  vessels  should  be  sought  for  in  the  supe- 
rior part,  at  the  inner  or  outer  side  of  the  wound,  because  in  its 
inferior  half  they  are  generally  very  small ;  we  should  likewise 
keep  in  mind,  that,  as  these  arteries  run  in  the  cellulo-adipose 
layer,  they  will  retract  as  soon  as  divided,  and  that  their  mouths 
will  also  contract  so  much  as  to  render  their  ligature  difficult 
after  the  removal  of  the  tumour.  It  is  with  the  view  of  avoiding 


OF    THE    CHEST.  417 

ihe  inconveniences  attached  to  this  disposition  of  the  arteries, 
that  surgeons  recommend  us  to  tie  them  as  soon  as  they  are  di- 
vided by  the  instrument.  This  advice,  dictated  by  prudence, 
ought  always  to  be  followed,  especially  when  we  wish  to  effect 
an  union  by  the  first  intention ;  then,  in  fact,  it  is  necessary  to 
prevent  the  blood  from  becoming  extravasated  behind  the  ap- 
proximated lips  of  the  wound,  if  we  wish  them  to  agglutinate : 
but  if  the  loss  of  the  substance  is  so  great  that  we  are  obliged  to 
dress  it  as  an  open  sore,  or  if  the  surgeon,  from  any  other  reason, 
does  not  think  proper  to  dress  it  otherwise,  we  think  that  it  would 
always  be  possible,  under  ordinary  circumstances,  to  secure  the 
arteries,  after  the  excision  of  the  diseased  parts,  so  that  there 
would  be  no  apprehension  of  severe  haemorrhage.  The  other 
method,  however,  has  no  other  defect  than  that  of  uselessly  pro- 
longing the  operation. 

iv.  The  Veins. 

Some  of  them  are  disposed  as  the  arteries,  which  they  accom- 
pany and  exceed  in  volume,  and  to  which  they  generally  adhere 
so  intimately  that  it  is  often  very  difficult  to  separate  them  :  the 
others  are  situated  under  the  skin  and  even  in  the  gland.  The 
arrangement  of  the  latter  is  very  different  from  that  of  the  arte- 
ries ;  they  intersect  each  other  a  great  number  of  times  in  the 
compact  tissue  which  unites  the  mammary  gland  to  the  skin  of 
the  areola ;  and,  in  women  who  have  nursed  many  children,  they 
form  a  species  of  plexus,  more  or  less  evident  and  complicated 
around  this  coloured  part.  As  we  remove  from  this  point,  the 
subcutaneous  veins  of  the  breast  are  so  large  that  they  are  delin- 
eated through  the  skin ;  indeed  it  is  not  uncommon  to  see  them 
become  varicose*  in  females,  of  a  certain  age,  who  have  fulfilled 
the  duties  of  maternity,  in  those  who  have  been  affected  with 
chronic  enlargement  of  the  breasts,  etc.  It  is  these  enlarged 
vessels  which  give  to  the  cancerous  breast  that  disagreeable  ap- 
pearance which  induced  the  ancients  to  compare  this  disease  to 
a  species  of  lobster,  or  crab,  sticking  to  the  organ  in  order  to  de- 
vour it.  The  veins  of  the  glandular  texture  have  very  thin 

*M.  Briquet,  th£se,  etc.  1824. 

53 


118 


OF    THE    CHEST. 


tunics,  and  are  always  larger  than  the  arteries ;  almost  all  of 
them  pass  into  the  veins  of  the  axilla,  some  empty  into  the  inter- 
nal jugular  or  subclavian,  on  the  inner  or  outer  side  of  the  sterno- 
mastoid  muscles,  and  may  be  lacerated  by  the  osseous  fragments, 
in  fractures  of  the  clavicle,  so  as  to  give  rise  to  extensive  ecehy- 
moses.  In  short,  all  these  vessels  soon  enter  into  the  surrounding 
regions,  where  we  have  already  examined  them. 

v.  The  Lymphatics. 

We  do  not  find  any  lymphatic  glands  in  the  mammary  region. 

The  vessels  are  a  continuation  of  those  which  were  pointed  out 
in  the  costal,  axillary  and  sternal  regions,  and  which  pass  to  the 
glands  in  the  anterior  media stinal  space  and  to  those  in  the  cavity 
of  the  axilla,  on  the  one  part ;  and  to  the  glands  of  the  infra-hyoi- 
deal  and  supra-clavicular  regions,  on  the  other. 

vi.   The  Nerves. 

These  are  also  the  same  branches  as  those  which  we  have  al- 
ready seen  in  the  other  regions  of  the  thorax. 

Thus,  the  supra-clavicular  filaments  of  the  cervical  plexus  en- 
ter this  region  in  order  to  ramify  in  the  skin  and  the  superficial 
laminae  of  the  cellular  layer  ;  the  thoracic  branches  of  the  brach- 
ial  plexus  are  distributed  to  the  gland  and  the  adipo-cellular  tis- 
sue ;  the  twigs  of  the  corresponding  intercostal  nerves,  and  those 
of  the  posterior  thoracic  are  also  lost  in  it,  after  having  passed 
through  the  muscles.  These  different  filaments  are  so  small  that 
their  diseases  cannot  be  correctly  appreciated :  from  analogy, 
however,  and  certain  facts,  we  are  induced  to  believe  that  they 
sometimes  undergo  changes  which  produce  in  the  breast  of 
females  exquisite  pain,  and  which  continues  during  a  long  time 
without  any  organic  lesions  being  observed  in  it. 

vn.  The  Mammary  Gland. 

Its  circumference  is  irregular ;  so  that,  in  extirpating  it,  some 
lobules  might  be  left  behind,  although  the  intention  was  to  remove 
the  whole  of  it.  Its  anterior  or  superficial  surface  is  uneven. 


OF    THE    CHEST*  419 

tuberculated,  convex,  and  separated  from  the  skin  by  a  layer  of 
cellular  and  adipose  tissue,  which  increases  in  thickness  in  pro- 
portion as  it  recedes  from  the  nipple.  Its  deep  surface  is  plane 
and  smooth,  being  covered  by  a  very  distinct  aponeurotic  fibrous 
sheet ;  it  is  separated  from  the  pectoralis  major  only  by  a  small 
number  of  cellular  lamellae ;  and  the  relations  of  the  gland  with 
this  muscle  vary  but  little,  whatsoever  may  be  the  embonpoint  of 
the  female.  The  divers  lobules  are  separated  by  processes  of 
fibro-cellular  tissue,  which  become  hard,  completely  fibrous,  and 
sometimes  cartilaginous  or  osseous,  in  scirrhous  enlargements 
(cancers  lardaces).  These  plates,  which  are  also  attached  to  the 
skin,  divide  the  organ  into  several  compartments,  and  permit  pus 
to  form  in  a  great  number  of  distinct  loculi :  therefore,  when 
abscesses  are  developed  in  the  breast,  it  is  not  unusual  to  see 
several  of  them  open  successively,  or  require  to  be  punctured 
separately.  In  colloid  or  gelatiniforme  cancers,  the  hydatiforme 
of  English  authors,  these  intersections  also  perform  an  important 
office.  They  give  to  these  tumours  that  lobulated  disposition, 
which  constitutes  one  of  their  principal  characters  ;  but  they 
never  extend  so  far  as  the  muscles  :  they  generally  terminate  in 
the  lamellated  layer  which  covers  the  gland  posteriorly.  In  the 
adipose  tissue,  on  the  contrary,  we  observe  these  intersections 
prolonged  in  all  directions,  which  prolongations  become  harden- 
ed, and  are  transformed  into  the  fibrous  or  scirrhous  texture  in 
cancers  of  this  nature,  of  which  they  then  seem  to  form  the  roots, 
and  which  we  should  carefully  remove,  if  we  wish  to  obtain  some 
chance  of  success  from  the  operation.  As  in  the  natural  state, 
and  especially  in  the  pathological,  the  gland  or  the  disorganizing 
tumour  descends  more  or  less  below  the  pectoralis  major  and  into 
the  grooves  which  separate  the  inferior  margin  of  this  muscle 
from  the  ribs,  it  is  necessary,  in  order  to  avoid'  dividing  this  fleshy 
border,  to  dissect  the  part  which  we  wish  to  remove,  from  above 
downwards.  It  is  also  necessary,  in  order  to  prevent  constant 
tractions  upon  the  cicatrix,  that  the  incisions  should  be  made  ob- 
liquely to  the  fibres  of  this  muscle,  that  is  to  say  from  above 
downwards  and  from  without  inwards  ;  finally,  in  order  that  the 
pains  which  its  contractions  occasion  during  the  treatment  of  the 
wound,  consequent  to  the  removal  of  the  breast,  may  be  mode-, 
rated,  it  is  necessary  that  the  arm  should  be  kept  immoveable. 


01     THE    CHEST. 

We  must  also  recollect,  in  relation  to  this  operation,  that  the  dis- 
ease frequently  obliges  us  to  remove  a  portion  of  the  muscle  in 
question  and  sometimes  even  of  the  ribs,  as  well  as  a  part  of  the 
pleura  itself,  as  is  proved  by  the  bold  operation  of  this  nature  per- 
formed by  M.  Richerand.  In  all  these  cases,  as  several  bundles 
of  the  pectoralis  major  remain  unmolested  above  the  cicatrix,  it 
follows  that,  after  the  cure,  the  arm  recovers  the  freedom  of  its 
movements  in  a  much  more  perfect  manner  than  would  at  first 
have  been  supposed. 

vin.  The  Lactiferous  Ducts. 

The  lactiferous  ducts  arise,  like  all  excretory  tubes,  by  a  great 
number  of  radicles,  in  the  lobules  of  the  gland,  and  some  of  them, 
according  to  Haller,  from  the  adipose  layer,  all  of  which  run 
towards  the  nipple  and  open  separately  upon  its  surface.  Some 
of  these  lie  so  near  the  skin,  and  are  sometimes  so  large  in  cer- 
tain women  during  lactation,  that  a  very  slight  incision  in  the 
neighborhood  of  the  areola,  may  open  them ;  in  which  case,  a 
fistula  may  be  the  consequence,  which  will  not  exist  however 
except  during  lactation.  These  canals  appear  to  be  the  special 
seat  of  the  disease  known  by  the  vulgar  name  of  "  ague  in  the 
breast"  or  engorgement  of  the  breast  of  lying-in  women.  In 
these  cases  it  really  seems  that  the  milk  coagulates  within  them, 
and  thereby  becomes  a  foreign  body,  irritating,  by  its  presence, 
and  producing  inflammation  of  the  surrounding  cellular  tissue. 
It  is  from  this  opinion  that  ammoniated  liniments  are  recommend- 
ed, for  the  purpose  of  restoring  to  the  milk  its  natural  fluidity, 
and  which  actually  produces  astonishing  effects,  when  employed 
by  a  skilful  and  prudent  physician. 

ART.    II.    OF   THE    INTERIOR    OP    THE    THORAX. 

We  have  now  to  examine  successively :  the  partition  which 
separates  the  chest  into  two  cavities,  and  the  organs  included  in 
this  partition  ;  the  two  pectoral  cavities  themselves,  in  their  rela- 
tions \vith  the  viscera  which  they  contain :  finally,  the  base  and 
the  summit  of  the  thorax. 


OF    THE    CHEST.  421 


i.  The  Median  Septum  or  Mcdiastinal  Region. 

By  making  an  abstraction  of  the  column  formed  by  the  bodies 
of  the  vertebra?,  which  prolong  this  septum  backwards,  we  ob- 
serve that  it  is  constituted  by  the  approximation  and  junction 
(adossement)  of  the  two  pleura?.  It  has  the  figure  of  a  triangle 
rounded  off  towards  the  summit  of  the  cavity  which  it  divides ; 
its  posterior  border  rests  upon  the  fore  part  of  the  spine,  and  fol- 
lows the  direction  of  this  column,  upon  the  sides  of  which,  the 
two  pleural  lamina?  are  applied. 

This  separation  of  the  two  pleurae  upon  the  anterior  part  of  the 
bodies  of  the  vertebrae,  constitutes  what  certain  anatomists  call  the 
posterior  mediastinum.  It  contains  the  aorta,  on  the  left;  the 
vena  azygos,  on  the  right ;  the  oesophagus,  before,  in  the  middle, 
and  upon  a  more  anterior  plane  ;  the  thoracic  duct,  behind ; 
lastly,  some  cellular  tissue,  lymphatic  glands,  etc. 

(  a  )  The  Aorta  does  not  penetrate  into  the  posterior  medias- 
tinal  space,  until  after  it  has  curved  around  the  left  bronchus ; 
then  it  places  itself  deeply  upon  the  corresponding  side  of  the  ver- 
tebra?, and,  as  it  descends  lower,  it  approximates  the  median  line 
and  becomes  more  anterior.  It  is  then  found  in  relation : — an- 
teriorly and  on  the  left,  with  the  pleura,  and  mediately  with  the 
root  of  the  left  lung,  the  pericardium  and  the  left  side  of  the 
heart  ;  internally  and  anteriorly,  with  the  oesophagus  and  the  par 
vagum  of  the  left  side,  which  from  being  a  half  inch  and  even  an 
inch  distant  from  it  above,  promptly  approximate  it  as  they  de- 
scend, and  are  united  to  it  below  by  a  pretty  dense  cellular  tissue. 
Its  posterior  and  internal  portion  rests  upon  the  vertebrae,  bet  ween 
the  thoracic  duct  which  runs  along  its  inner  side,  and  the  great 
sympathetic  which  is  situated  on  its  outer  side ;  so  that  it  crosses 
all  the  costo-vertebral  articulations.  From  this  disposition  of  the 
great  artery  of  the  body,  we  may  perceive  that  its  aneurismal 
tumours  will  compress  different  organs,  according  to  the  point 
which  they  may  occupy  below  the  transverse  portion  of  its  arch. 
Thus,  if  the  aneurism  is  situated  above,  and  it  projects  forward,  it 
will  compress  and  flatten  the  left  bronchus  and  pulmonary  ves- 
sels :  whence  will  result  the  difficulty  of  breathing  and  the  dis- 
turbance in  the  circulation,  which  we  so  often  observe  in  this  dis- 


42*2  OF    THE    CHEST. 

ease.  If  this  tumour  is  situated  lower  down,  it  will  either  com- 
press the  cesphagus,  the  nervi  vagi  and  the  thoracic  duct,  if  it  is 
developed  on  the  right  side  :  or  it  will  push  the  heart  forwards,  if 
it  is  situated  upon  the  anterior  and  left  portion  of  the  artery ; 
finally,  it  will  act  more  particularly  upon  the  vertebral  column 
and  the  great  splanchnic  or  ganglionic  nerves.  It  is  on  account 
of  this  disposition,  that  aneurisms  may  open  into  the  bronchi  or 
oesophagus  ;  that  they  may  burst  still  more  frequently  into  the 
thorax  ;  that  they  may  occasion  disturbance  in  the  digestion  and 
circulation  of  the  chyle,  nervous  symptoms,  and  sometimes  pro- 
duce absorption  of  the  bodies  of  the  vertebrae  ;  the  fibro-cartila- 
ges,  etc.,  remaining  for  a  longer  time  unmolested. 

The  aorta  gives  off,  in  the  space  which  we  are  examining,  the 
intercostales,  mediastinales  posteriores,  bronchiales,  and  cesopha- 
gea3.  None  of  these  branches  are  so  large  as  to  merit  of  them- 
selves much  attention ;  we  should  note,  however,  that  the  first 
anastomose  with  the  internal  mammary,  and  superior  intercostal, 
which  are  derived  from  the  subclavian,  and  with  several  branches 
from  the  axillary,  so  as  to  furnish  a  connected  chain  between  it 
and  the  lumbar,  epigastric,  etc.  arteries ;  a  chain  which  seems  to 
be  capable  of  continuing  the  circulation  in  case  the  aorta  should 
be  obliterated,  as  has  been  observed  by  Dr.  Graham.* 

(  b )  The  vena  azyos,  which  receives  directly  almost  all  the  in- 
tercostal veins  of  the  right  side,  where  it  is  disposed  as  the  aorta 
is  on  the  left,  is  also  the  rendezvous  of  the  most  of  those  of  this  last 
side,  by  means  of  the  demi-azygos,  which  has  crossed  the  spine 
transversely  under  the  aorta  and  oesophagus.  But  at  the  mo- 
ment this  vein  turns  over  the  right  bronchus,  it  ceases  to  apper- 
tain to  the  posterior  mediastinal  space.  The  azygofe  is  only  of 
importance  in  surgery,  inasmuch  as  it  forms  an  union  between  the 
two  venae  cava?,  and  might  thereby  re-establish  the  venous  circu- 
lation, if  the  calibre  of  one  of  these  large  vessels  should  be  oblit- 
erated between  their  termination  in  the  auricle  and  the  points 
where  they  receive  the  extremities  of  the  azygos. 

( c  )  The  (Esophagus  is  covered  by  the  trachea,  in  the  same 
manner  as  in  the  neck,  as  far  as  the  origin  of  the  bronchi  ;  its 
posterior  relations  are  similar  also  on  the  left ;  it  is  coasted  by  the 

*  Med.  Chir.  Transactions,  vol.  5, 


OF   THE    CHEST.  423 

common  carotid  and  sub-clavian  arteries  on  the  right ;  it  is  not 
very  remote  from  the  arteria  innominata  and  superior  cava ;  con- 
sequently this  tube  might  be  compressed  by  an  aneurism  of  the 
arteries  which  originate  from  the  arch  of  the  aorta.  As  it  con- 
tinues to  descend  it  inclines  slightly  to  the  right,  passes  behind 
the  trunk  of  the  pulmonary  artery,  the  origin  of  the  aorta,  the 
heart  and  the  inclined  portion  of  the  diaphragm,  having  behind 
it  and  upon  its  sides  the  right  intercostal  arteries  and  the  aorta, 
the  left  intercostal  veins  and  the  vena  azygos,  the  thoracic  duct, 
some  lymphatic  glands,  and,  in  a  more  or  less  remote  manner, 
the  dorsal  vertebrae.  Beginning  from  the  bronchi,  it  is  also  sur- 
rounded by  the  two  nerves  of  the  eight  pair,  which  forms  a  spe- 
cies of  plexus  around  it.  Before  it  passes  into  the  abdomen,  it 
again  inclines  towards  the  left,  and  thus  forms  in  the  chest  an 
elongated  curvature,  the  convexity  of  which  looks  towards  the 
right,  whilst  in  the  infra-hyoideal  region,  we  observe  an  opposite 
disposition.  This  direction  should  be  kept  in  mind,  when  we  at- 
tempt to  pass  instruments  from  the  mouth  into  the  stomach.  It  is 
unnecessary  to  state  that,  if  the  oesophagus  was  the  seat  of  tu- 
mours, it  might  compress  the  aorta  and  all  the  other  canals 
which  surround  it,  and  that  the  nervous  plexus,  which  covers  it, 
sufficiently  accounts  for  those  dull  and  sometimes  acute  pains, 
which  are  experienced  when  aliments  or  any  other  substances 
are  arrested  in  their  progress  through  it. 

( d )  The  Thoracic  duct,  placed  between  the  organs  which  we 
have  just  examined,  behind  the  oesophagus,  is  at  first  on  the  right 
of  the  median  line,  which  it  approximates  more  and  more  in  pro- 
portion as  it  ascends,  and  finally  passes  to  the  left  towards  the  up- 
per part  of  the  fourth  dorsal  vertebra.  It  is  enveloped  in  an  ex- 
tensible cellular  tissue,  adheres  but  slightly  to  the  other  organs, 
which  may  nevertheless  compress  it  against  the  vertebral  column 
when  their  dimensions  are  augmented  in  consequence  of  morbid 
alterations.  Its  diseases  are  as  yet  but  little  kno\vn  ;  M.  Andral 
Jun.,  however,  has  met  with  it  degenerated  into  a  tuberculous 
matter,  which  also  filled  its  cavity.  In  a  subject  dissected  by  Dr. 
Riley,in  March  1825,  at  the  ecole-pratique,  we  found  it  in  a  vari- 
ricose  state,  dilated  in  different  places  to  the  size  of  the  little  finger. 

(c)  The  Lymphatic  Glands  are  numerous  here,  and  form  a 
kind  of  chain ;  they  are  traversed  by  almost  all  the  lymphatics 
of  the  abdomen,  and  receive  those  of  the  thoracic  parietes,  which 


OF    THE    CHEST. 

accompany  the  intercostal  vessels ;  hence,  they  frequently  be- 
come swollen  from  scrofulous,  and  cancerous  diseases,  etc., 
which  have  their  seat  in  the  sides  of  the  chest,  or  in  the  belly. 
From  the  anatomical  relations  we  perceive,  that,  if  they  should 
become  greatly  enlarged,  they  will  displace  the  heart,  aorta, 
cesophagus,  etc.  or  compress  and  flatten  these  organs;  and 
thereby  occasion  serous  infiltrations,  indigestion,  marasmus  and 
difficult  respiration. 

(/)  The  Cellular  tissue  is  always  abundant  in  this  space; 
superiorly,  it  communicates  with  the  deep  cellular  tissue  of  the 
neck ;  so  that  the  pus  which  forms  in  the  infra-hyoideal  region 
may  readily  descend  in  the  chest  along  the  spine,  without  being 
extravasated  into  the  pleurae.  Inferiorly,  this  tissue  forms  a  com- 
munication between  the  posterior  mediastinal  space  and  the  ab- 
dominal cavity,  by  means  of  the  apertures  through  which  the 
cesophagus  and  aorta  pass,  and  may  thus  conduct  into  the  belly, 
behind  the  peritoneum,  fluids  which  have  been  secreted  into  the 
posterior  interval  of  the  thoracic  septum.  It  is  in  this  manner 
that  a  great  many  abscesses  by  congestion*  are  formed. 

Anterior  to  these  different  parts  the  pleurae  are  arranged  in 
the  following  manner :  they  are  completely  joined  at  the  fore 
part  of  the  cesophagus,  from  the  diaphragm  to  the  base  of  the 
heart,  below  which  they  are  equally  in  contact,  but  much  nearer 
the  vertebrae ;  in  fact  they  touch  each  other  even  behind  the 
oesophagus,  because  the  aorta  and  vena  azygos  do  not  exist  be- 
tween them  until  they  get  on  a  level  with  the  third  dorsal  ver- 
teba,  opposite  to  the  heart.  These  laminae  separate  much  more, 
on  the  contrary,  in  order  to  envelope  this  organ,  so  that  the  spe- 
cies of  triangular  canal  formed  by  the  mediastinum  posteriorly, 
is  at  first  very  narrow,  but  afterwards  very  broad,  and  contains 
a  great  abundance  of  cellular  tissue  behind  the  heart ;  that  at 
length  it  includes  entirely  the  aorta,  oesophagus,  etc.  below  the 
central  organ  of  the  circulation.  After  these  two  membranes  have 
become  more  or  less  intimately  joined  anteriorly,  they  again 
diverge  from  each  other  and  produce  another  space  behind  the 
sternum,  which  appertains  to  the  anterior  border  of  the  medi- 
astinum, and  which  we  find  described  by  several  authors  under 
the  name, of  anterior  mediastinum.  This  space,  the  existence  of 

*  Jibces  par  congestion,  purulent  collections  which  derive  their  origin  from  a 
remote  point. — Transl. 


OF    THE     CHEST.  425 

which  has  been  denied  by  Bartholin,  Ruysch,  Winslow,  and 
which  Gavard  says  he  never  met  with,  was  admitted  by  Hunter, 
Senac,  Sabatier ;  and  all  anatomists  of  the  present  day  are  of 
the  latter  opinion.  We  must  not,  however,  judge  of  its  dimen- 
sions during  life,  from  what  we  observe  upon  the  dead  body, 
a/ter  the  sternum  is  removed.  In  fact,  if  for  the  purpose  of  ex- 
amining it,  we  remove  all  the  ribs  except  the  first  and  last,  in 
order  to  maintain  the  sternum  in  place,  we  distinctly  perceive 
that  the  right  pleura  is  adherent  very  near  the  median  line  of 
the  posterior  face  of  the  breast  bone,  and  that  the  left,  although 
much  nearer  the  border  of  this  bone  below,  does  not,  however, 
entirely  abandon  it.  Be  this  as  it  may,  the  anterior  splitting  of 
the  mediastinal  septum,  and  the  space  thereby  produced  pass 
obliquely  from  right  to  left  and  from  above  downwards  ;  so  that 
in  order  to  penetrate  into  the  thorax  without  perforating  the 
pleura?,  we  should  choose  the  median  line  above,  and  the  left 
side  of  the  sternum  below ;  in  cases,  for  example,  in  which  the 
supple  and  abundant  cellular  tissue  which  fills  this  space  is  in- 
flamed to  such  a  degree  as  to  occasion  an  abscess,  as  Avenzoar 
states  occurred  in  himself,  we  might,  by  recollecting  this  dispo- 
sition, perforate  the  sternum  and  give  exit  to  the  fluid,  as  advised 
by  Columbus,  and  practised  by  Purmann  and  La  Martiniere. 
The  case  related  by  Salius-Diversus  proves  that  the  inflamma- 
tion of  the  cellular  tissue  contained  in  this  space,  may  occasion 
the  death  of  the  patient,  notwithstanding  it  may  have  remained 
circumscribed  in  it ;  those  by  Carpi,  Marchetti,  Spigel,  demon- 
strate that  penetrating  wounds  in  this  situation,  do  not  necessa- 
rily open  the  serous  cavities ;  and,  from  what  Freind  says,  we 
perceive  that  syphilitic  affections  may  sometimes  occasion  pur- 
ulent collections  here,  which  might  be  discharged  by  means  of 
the  trepan. 

Furthermore,  this  space  represents  pretty  correctly  two  trian- 
gles joined  by  their  apex  before  the  anterior  ventricle  of  the 
heart.  In  the  first  triangle,  the  base  of  which  ascends  almost  to 
the  supra-sternal  notch,  we  find  some  lymphatic  glands,  much 
cellular  tissue,  the  thymus  in  the  infant,  and  the  mammary  ar- 
tery. When  these  parts  are  unusually  developed,  or  when  they 
become  the  seat  of  tumours  of  moderate  volume,  as  they  cannot 

54 


OF    THE    CHEST, 


protrude  externally  through  the  sternum,  they  ascend  in  the 
neck,  pass  upon  the  trachea,  and  are  sometimes  mistaken  for 
diseases  of  the  thyroid  gland ;  or  they  may  project  backwards 
and  compress  the  arch  of  the  aorta  and  the  large  branches  which 
arise  from  it,  the  superior  cava  and  subclavian  veins.  The  sec- 
ond triangle  is  of  greater  length ;  its  left  side  descends  as  low  as 
the  posterior  surface  of  the  eighth  cartilage ;  it  is  filled  with  cel- 
lular tissue,  lymphatic  glands,  and  discovers  the  anterior  surface 
of  the  pericardium.  It  is  in  consequence  of  this  disposition  that 
M.  Laennec  advises  opening  this  bag,  by  trepanning  the  left  side 
and  lower  part  of  the  sternum.  By  this  operation,  which  was 
first  proposed  by  Senac,  we  would  avoid  opening  the  pleura? ; 
whereas  Desault,  Skeildrup  and  Romero,  in  their  essays,  could 
not  reach  the  pericardium  without  transfixing  the  left  thoracic  se- 
rous membrane. 

Superiorly,  the  cellular  tissue  which  fills  the  anterior  medias- 
tinal  space  is  continuous  with  that  upon  the  fore  part  of  the  tra- 
chea, and  with  the  sub-aponeurotic  lamella  of  the  neck ;  inferi- 
orly,  this  tissue  is  prolonged  between  the  peritoneum  and  abdom- 
inal muscles,  in  passing  behind  the  cartilago  ensiformis,  through 
an  aperture,  of  greater  or  less  breadth,  which  separates  the  ante- 
rior digitations  of  the  diaphragm.  Hence  it  follows  that  tumours 
formed  behind  the  sternal  appendix  may  be  prolonged  almost  to 
the  neck  by  following  this  space  ;  that  abscesses  especially  will 
easily  descend  from  the  infra-hyoideal  region  and  make  their  ap- 
pearance in  the  epigastric  region,  etc.,  and  that,  on  the  other 
hand,  the  same  diseases,  primitively  developed  in  the  inferior 
triangle  of  this  space,  might  be  prolonged  into  the  epigastric 
region. 

We  must  also  recollect  that  the  internal  mammary  artery 
runs  along  the  borders  of  the  sub-sternal  mediastinal  space 
throughout  its  whole  extent,  and  that  the  lymphatic  glands  are 
principally  met  with  in  the  track  of  this  vessel.  All  the  other 
organs  which  we  perceive  in  the  bottom  of  this  separation,  ap- 
pertain more  especially  to  the  septum  itself. 

The  inferior  border  of  the  mediastinum,  resting  upon  the  dia- 
phragm, presents,  anteriorly,  the  broadest  part  of  the  sub-ster- 
nal space;  in  the  middle,  a  separation,  which  is  still  more  exten- 


OF    THE    CHEST.  427 

sive,  for  the  lodgement  of  the  pericardium;  posteriorly,  the 
pleurae  are  in  contact  upon  the  fore  part  of  the  oesophagus,  and 
again  separate  to  form  the  spinal  space. 

At  the  summit,  all  the  parts  are  confounded  in  the  superior 
opening  of  the  thorax ;  but  the  pleurae  are  very  much  separated. 

In  the  inferior  half  of  the  mediastinal  septum  we  find  the 
heart,  pericardium,  and  inferior  and  superior  venae  cavae.  The 
position  of  the  heart  is  such  that  its  apex  strikes  the  fifth  inter- 
costal space  and  the  sixth  rib  on  the  left  side,  whilst  on  the  right, 
it  does  not  pass  beyond  the  sternum :  therefore  penetrating 
wounds  are  much  more  dangerous  in  the  first  direction  than  in 
the  second :  hence,  also,  it  is  its  right  ventricle  which  is  most 
exposed  to  the  action  of  vulnerant  bodies,  unless  they  have  been 
directed  transversely;  and  it  is  the  importance  of  the  functions  of 
this  organ  especially  which  renders  its  wounds  so  serious.  Some 
facts,  however,  would  lead  us  to  believe  that  wounds  which 
even  penetrate  into  its  cavities  are  not  constantly  fatal.  The 
case  related  by  Latour  of  Orleans,  in  which  it  is  stated  that  a 
man  lived  six  years  after  having  been  wounded  in  the  chest  by 
a  ball,  although  on  autopsic  examination  the  foreign  body  was 
found  in  the  cardiac  septum,  is  one  of  the  most  inexplicable.  In 
1818  we,  in  conjunction  with  M.  Bretonneau,  transfixed  the 
heart  of  several  dogs,  with  thick  needles,  and  in  several  of  these 
animals  no  disturbance  followed.  In  1822,  we  repeated  this 
experiment  in  public,  in  the  amphitheatre  of  the  Ecole-pratique, 
upon  a  dog  of  middle  size ;  we  passed  a  needle  six  inches  long 
through  the  heart,  four  different  times,  no  inconvenience  resulted, 
and  the  animal  enjoyed  good  health  six  months  after. 

A  collier,  fifty  years  of  age,  of  intemperate  habits,  died  at  the 
hospital  of  la  Faculte,  in  the  beginning  of  the  present  year.  In  a 
quarrel  nine  years  previous,  a  common  table  knife  was  thrust  into 
the  thorax  of  this  man,  through  the  left  side.  For  several  months 
it  was  expected  that  the  wound  would  prove  mortal ;  but  the 
patient  at  length  recovered,  remaining  subject  to  palpitations. 
On  examining  the  body  we  found  the  pericardium  opened  oppo- 
site to  the  cicatrix  in  the  thoracic  parietes.  and  the  heart  itself 
presented  a  fibrous  line  which  extended  throughout  the  entire 
thickness  of  the  right  ventricle,  in  the  place  corresponding  to 
the  loss  of  substance  in  the  pericardium.  Professor  Bougon, 


428 


or  nir; 


shewed  this  specimen  to  the  Royal  Academy  of  Surgery,  and 
Baron  Larrey  has  obtained  a  drawing  of  it. 

The  pericardium,  divested  of  the  serous  laminae  which  cover  it 
internally  and  externally,  seems  actually  to  be  a  continuation  of 
the  cordiform  tendon  of  the  diaphragm  ;  its  tissue  becomes  less 
dense,  less  compact,  where  it  approaches  the  principal  arteries, 
upon  which  it  is  confounded  with  their  external  tunic  ;  that  is  to 
say,  that  around  the  aorta  and  the  trunks  which  originate  from 
its  arch,  the  superior  cava  and  the  bronchi,  the  pericardium  is 
transformed  into  lamellae  analogous  to  those  which  envelope  the 
trachea,  oesophagus  and  the  large  vessels  of  the  neck  ;  or  rather 
that  the  diverse  deep  sheaths  of  the  infra-hyoideal  region  ap- 
proximate each  other  inferiorly,  and  unite  upon  the  origin  and 
termination  of  the  large  vessels  which  proceed  from  or  enter  the 
heart,  in  order  to  form  the  fibrous  sheet  of  the  pericardium,  and 
in  this  manner  become  blended  with  the  diaphragm,  and  even 
traverse  it  by  being  prolonged  upon  the  vena  cava,  oesophagus 
and  aorta.  Hence  it  follows,  as  Dr.  Godman  has  very  satisfacto- 
rily demonstrated,  that  the  pericardium  is  continuous,  without  in- 
terruption, with  the  aponeuroses  of  the  neck,  on  the  one  hand, 
and  on  the  other,  with  the  fibrous  layers  of  the  abdomen,  by 
means  of  the  sheaths  which  cover  the  aorta,  oesophagus,  etc.,  and 
that  pus,  or  inflammations  may  easily  extend  from  one  of  these 
regions  into  the  other. 

The  inferior  vena  cava  is  here  seen  even  in  the  cavity  of  the 
pericardium,  which  it  does  not  abandon  until  it  traverses  the  dia- 
phragm. Free  between  the  oesophagus,  the  heart  and  lungs,  it  is 
by  this  means  protected,  as  it  were,  against  every  compression 
capable  of  completely  obliterating  its  calibre  ;  but  it  may  be  dis- 
placed by  the  dilatation  of  the  heart,  in  aneurisms,  by  the  right 
lung  when  swollen  and  hepatized  in  pneumonia,  and  thereby 
curved  in  such  a  manner  as  to  impede  the  venous  circulation  : 
whence  doubtless  arises  the  engorgement  of  the  liver,  so  common 
in  these  diseases  and  in  phthisis,  etc. 

Above  the  heart,  in  the  mediastinal  septum,  we  find  the  sub- 
sternal  curvature  of  the  aorta,  the  convexity  of  which,  turned 
forwards  and  to  the  left,  is  only  separated  from  the  first  portion 
of  the  sternum  by  some  cellular  laminae  ;  from  which  circum- 
stance, the  aneurysmatic  dilatation  of  this  trunk  often  determines 


OF   THE    CHEST.  1*29 

absorption  or  caries  of  the  bone  which  covers  it.  On  the  left, 
the  aorta  is  crossed  by  the  phrenic  nerve,  par  vagum  and  the  re- 
current, which  embraces  its  concavity  in  order  to  pass  back  into 
the  infra-hyoideal  region.  As  it  occasionally  happens  that  per- 
sons afflicted  with  aneurism  of  the  arch  of  the  aorta  lose  their 
voice,  the  old  surgeons  attributed  this  phenomenon  to  pressure 
on  the  inferior  laryngeal  nerves.  It  is  true  that  this  cause  may 
sometimes  contribute  towards  it ;  but  it  is  also  probable  that  this 
accident  most  frequently  depends  upon  the  compression  of  the 
bronchi  or  trachea,  which  are  surrounded  by  the  artery  or  placed 
behind  it.  Furthermore,  when  the  aortic  arch,  while  yet  within 
the  pericardium,  is  morbidly  dilated,  it  will  compress,  anteriorly, 
the  anterior  portion  of  this  membrane,  the  cellular  tissue,  lymph- 
atic glands,  internal  mammary  vessels,  and  sternum  ;  exterior  to 
the  pericardium,  the  thymus  in  the  infant,  a  greater  abundance  of 
cellular  tissue,  and  the  same  parts  as  lower  down  ;  posteriorly, 
the  pulmonary  artery,  the  termination  of  the  trachea ;  more  deep- 
ly, the  oesophagus,  thoracic  duct,  cellular  tissue,  lymphatic  glands 
and  the  spine  ;  on  the  left,  the  bronchus,  the  pulnionary  artery 
and  the  two  pulmonary  veins  of  this  side,  the  par  vagum  and 
phrenic  nerves,  and  the  top  of  the  lung ;  on  the  right,  the  pul- 
monary artery,  superior  vena  cava,  the  same  nerves  as  on  the  left, 
but  in  a  less  direct  mariner  :  consequently,  these  tumours  would 
disturb  respiration  and  suspend  the  voice  ;  would  impair  diges- 
tion by  the  compression  of  the  nerves,  and  prevent  deglutition  by 
obliterating  the  oesophagus  ;  would  obstruct  the  passage  of  the 
arterial  blood  into  the  lungs,  and  oppose  the  return  of  the  venous 
blood  from  these  organs  into  the  left  auricle  ;  would  impede  the 
venous  circulation  of  the  superior  parts,  by  pressing  upon  the  ve- 
na cava ;  derange  the  course  of  the  chyle  and  lymph  ;  and  lastly, 
occasion  absorption  or  caries  of  the  vertebrae  and  sternum. 

From  these  relations  we  may  also  explain,  how  it  happens  that 
the  rupture  of  these  aneurisms  sometimes  takes  place  into  the  left 
bronchus  or  trachea,  and  into  the  oesophagus. 

The  pulmonary  artery  comes  next  to  the  aorta,  which  it  turns 
upon  from  below  upwards,  from  right  to  left,  and  from  before 
backwards ;  it  is  still  in  the  pericardium  when  it  divides,  and  its 
two  branches,  in  their  course  to  the  root  of  the  lungs,  circum- 
scribe an  irregular  rhomboid  with  the  bronchi,  the  anterior  sur- 


430  OF    THE    CHEST. 

face  of  which  they  cross,  in  order  to  place  themselves  between 
them  and  the  pulmonary  veins.  That  of  the  right  side  is  the 
longest  and  largest ;  it  is  covered  by  the  aorta,  superior  vena 
cava  and  the  vena  azygos.  Poteriorly,  it  rests  upon  the  right 
pulmonary  veins  ;  a  little  higher,  upon  the  oesophagus,  then  upon 
the  corresponding  bronchus ;  its  anterior  part  is  also  crossed  by 
the  phrenic  nerve,  between  the  vena  cava  and  the  aorta  ;  by  the 
cardiac  ganglion  and  plexus,  which  separate  it  from  the  latter. 
The  left  pulmonary  artery  is  shorter  and  smaller  than  the  other ; 
it  rests,  at  first,  upon  the  left  auricle,  and,  in  a  remote  manner, 
upon  the  thoracic  aorta  ;  it  is  next  situated  upon  the  fore  part  of 
the  bronchus ;  the  lung  conceals  it  before,  and  the  aortic  curva- 
ture turns  over  it,  embracing  the  pulmonary  root ;  on  this  side, 
the  diaphragmatic  nerve  is  more  immediately  applied  to  it  than 
upon  that  of  the  right.  From  these  relations  it  is  evident,  that, 
if  the  pulmonary  arteries  became  aneurysmatic,  they  would 
react  in  a  serious  manner  upon  the  aorta,  vena  cava  and  pulmo- 
nary veins,  the  bronchi,  phrenic  nerves,  etc. 

The  Pulmonary  Veins  are  not  of  equal  lengths :  those  of  the 
left  side,  which  are  scarcely  an  inch  in  length,  place  themselves 
immediately  before  the  primary  divisions  of  the  bronchi,  run  at 
first  below  the  artery,  but  afterwards  are  situated  upon  its  ante- 
rior surface,  previous  to  penetrating  into  the  lung ;  those  of  the 
right  side  are  covered  by  the  trunk  of  the  pulmonary  artery,  the 
aorta,  superior  cava,  and  terminate  in  the  same  manner  as  on  the 
left. 

The  superior  vena  cava  is,  consequently,  anterior  to  all  these 
parts,  and  lies  very  near  the  sternum ;  the  phrenic  nerve  is  be- 
fore it,  superiorly ;  but,  in  descending,  passes  to  its  outer  side. 
The  par  vagum  runs  along  its  internal  side,  and  remains  more 
superficial  than  the  trachea,  as  far  as  its  bifurcation  ;  but  then  it 
dips  deeper,  and  directs  its  course  behind  the  pulmonary  root. 
On  the  left,  these  two  nerves  pass  upon  the  corresponding  face 
of  the  aorta,  and  are  thus  situated  upon  a  posterior  plane ;  the 
phrenic  nerve  continues  its  route  before  the  pulmonary  vessels, 
and  penetrates,  as  on  the  right,  between  the  Iamiria3  of  the  peri- 
cardium ;  so  that,  when  the  heart  is  greatly  dilated,  these  cords 
may  be  put  on  the  stretch,  and  occasion  pains  in  the  neck  as  well 
as  other  nervous  phenomena.  In  addition  to  the  pulmonary  ves- 


THE    CHEST.  431 


- 


*els  and  bronchi,  which  unite  and  intermingle  in  order  to  form  the 
root  of  the  respiratory  organs,  we  also  observe  here  a  great  num- 
ber of  lymphatic  glands,  which,  from  their  situation,  are  called 
bronchial.  These  glands  receive  all  the  lymphatics  of  the  lung, 
and  frequently  become  swollen  and  disorganized  in  phthisis,  in 
scrofulous  persons,  during  the  measles,  hooping  cough,  and  seve- 
ral chronic  inflammations  of  the  middle  membrane  of  the  respi- 
ratory passages.  In  such  cases,  they  may  compress  the  pulmo- 
nary veins  or  arteries,  the  bronchial  vessels,  and  greatly  derange 
the  process  of  sanguification ;  they  will  also  frequently  press 
upon  the  bronchi,  and  contract  adhesions  with  them ;  they  will 
even  perforate  them,  and  if  they  suppurate,  the  fluid  will  be 
evacuated  by  these  canals,  as  has  been  observed  by  M.  Guersent. 
In  a  word,  these  organs  are  susceptible,  in  these  cases,  of  giving 
rise  to  all  the  phenomena  of  compression  which  the  dilatation  of 
•ne  of  the  principal  arterial  trunks  ordinarily  determines. 

As  we  advance  near  the  summit  of  the  chest,  the  mediastinum 
encloses,  from  right  to  left,  and  from  before  backwards,  the  su- 
perior vena  cava,  which  has  received  the  subclavian,  the  right 
internal  mammary,  etc. ;  the  arteria  innominata,  before  and  on 
the  outer  side  of  which  are  seen  the  nerves  of  the  lung  and  of 
the  diaphragm  ;  lastly,  the  carotid  and  subclavian  arteries  of  the 
left  side. 

The  arteria  innominata  or  brachio-cephalic  trunk,  is  here  the 
most  important  organ ;  it  is  about  an  inch  and  a  half  in  length ; 
it  ascends,  inclining  slightly  to  the  right,  to  a  level  with  the 
sterno-clavicular  articulation,  where  it  divides,  opposite  to  the 
point  which  separates  the  two  portions  of  the  sterno-mastoid 
muscle.  It  is  covered,  from  the  deep  parts  towards  the  skin,  by 
the  par  vagum  and  right  cardiac  nerves ;  by  the  termination  of 
the  internal  jugular,  subclavian  and  thyroid  veins,  and  the  supe- 
rior cava ;  by  the  origins  of  the  sterno-thyroid  and  sterno-hyoid 
muscles ;  by  the  sternum,  the  head  of  the  clavicle  and  the  in- 
ternal tendon  of  the  sterno-mastoid  muscle ;  besides,  the  dif- 
ferent veins  and  the  artery  are  enveloped  in  this  place  by  a  very 
strong  fibro-cellular  lamina ;  posteriorly  it  is  removed  from  the 
trachea  by  some  lymphatics  and  cellular  tissue ;  on  the  right,  it 
is  very  close  to  the  pleura ;  finally,  this  trunk  is  so  disposed,  in 
the  healthy  state,  that  in  order  to  discover  it,  it  would  be  neces- 


432  OF   THE    CHEST. 

sary  to  depress  the  right  shoulder  firmly,  at  the  same  tune  thai 
the  head  is  thrown  backwards  and  to  the  left,  as  much  as  the 
position  of  the  disease  will  permit ;  to  divide  the  sternal  tendon 
of  the  sterno-mastoid  muscle;  to  separate  some  veins  which 
descend  behind  this  muscle ;  to  cut  across  the  sterno-hyoid  and 
sterno-thyroid  muscles;  to  tear  through  a  thick  and  strong- 
fibrous  plate ;  to  depress  the  left  subclavian  vein,  pushing  back 
the  jugular,  par  vagum  and  phrenic  nerves  toward  the  summit 
of  the  right  lung,  and  lastly  to  pass  a  thread  around  the  artery, 
by  introducing  the  aneurismal  needle  from  before  backwards 
and  from  right  to  left,  taking  great  care  to  avoid  the  right  pleura 
and  trachea.  If  we  wished  to  discover  the  brachio-cephalic 
trunk  by  trepanning  the  sternum,  as  was  mentioned  in  the  an- 
terior region  of  the  chest,  we  should  seize  the  artery  below  the 
left  subclavian  vein ;  but  it  is  important  to  remark  that  it  is  ne- 
cessary here  to  apply  the  ligature  as  high  as  possible,  on  account 
of  the  proximity  of  the  aorta,  which  must  render  the  formation  of 
the  clot  in  the  root  of  the  vessel  which  we  wish  to  obliterate, 
less  sure,  if  the  thread  is  carried  low  down  upon  the  artery.  In 
whatever  manner  this  operation  may  be  performed,  it  is  one  of 
the  most  difficult  and  dangerous  in  surgery ;  upon  the  living  sub- 
ject, there  must  be  something  dreadful  in  it,  and  it  requires  all 
the  knowledge  and  all  the  bold  dexterity  of  modern  surgeons,  in 
order  to  dare  to  undertake  it ;  indeed,  it  would  seem,  a  priori, 
almost  rashness  to  think  of  it,  especially  because  it  would  appear 
as  if  the  circulation  must  immediately  cease  in  the  right  superior 
extremity,  which  does  not  receive  any  other  arteries  than  those 
which  it  derives  from  the  innominata.  But  reasoning  must  be 
silent,  since  observation  has  spoken.  Twice,  in  fact,  has  this 
operation  been  performed :  once  in  New- York  by  Dr.  Mott,  and 
once  in  Germany,  by  Graefe.*  Notwithstanding  they  were  not 
attended  with  complete  success,  these  essays  at  least  prove  that 
life  will  be  preserved  in  the  limb  and  the  other  parts  to  which 
the  arteria  innominata  sends  its  branches,  since,  in  the  first  case, 
the  patient  lived  until  the  sixteenth  day,  and  in  the  second,  about 

*  We  have  just  been  informed  that  the  patient  of  M.  Graefe  survived  four 
weeks,  and  that  the  operation  would  perhaps  have  been  attended  with  complete 
success,  if  this  dexterous  surgeon  had  not  removed  too  soon  the  serre-nteud  which 
he  is  in  the  habit  of  employing  and  which  he  had  applied  upon  the  artery. 


OP   THE    CHEST. 

thirty  days :  then  the  circulation  must  have  been  maintained  by 
the  inosculations  of  the  arteries,  of  one  side  with  those  of  the 
other. 

As  the  brachio-cephalic  trunk  is  supported  by  the  sternum,  it 
must,  when  diseased,  readily  compress  the  trachea  and  even  the 
resophagus,  behind ;  the  cava  and  subclavian  veins  before ;  the 
par  vagum  on  the  right,  and  the  carotid  on  the  left.  Aneurismal 
tumours  may  be  prolonged  into  the  infra-hyoideal  region,  and  be 
mistaken  for  aneurisms  of  the  common  carotid  artery.  Burns 
has  delineated  in  his  work  on  the  surgical  anatomy  of  the  neck,  a 
remarkable  example  of  this  kind,  and  we  can  conceive  how  dan- 
gerous it  would  be  to  mistake  such  a  case,  if  we  determined  to 
seek  for  the  artery  below  the  tumour.  Anomalies  of  the  arteria 
irmnininata  are  very  rare;  nevertheless,  wre  possess  some  pretty 
remarkable  specimens  of  them,  and  during  the  preceding  winter, 
we  met  with,  in  the  dissecting  rooms  of  the  Ecole-pratique,  a  va- 
riety in  the  position  of  this  vessel,  which  would  have  rendered  its 
ligature  impossible:  after  its  origin,  the  arteria  innominata 
passed  to  the  left,  in  order  to  turn  over  the  trachea,  then  pene- 
trated between  this  organ  and  the  oesophagus,  and  replaced  itself 
on  the  right  side  at  the  moment  of  its  bifurcation,  but  much  more 
deeply  than  in  the  natural  state. 

The  relations  of  the  left  carotid,  in  the  upper  part  of  the  me- 
diastinum, are  the  same  as  in  the  lower  part  of  the  neck ;  ante- 
riorly, it  is  covered  by  the  thymus  gland  in  the  child,  some  lax 
cellular  tissue  and  lymphatic  glands  in  the  adult,  by  the  subclavian 
vein,  the  left  sterno-thyroid  and  sterno-hyoid  muscles  ;  lastly,  by 
the  sternum  and  sterno-clavicular  articulation :  posteriori}7,  it  is 
removed  from  the  vertebra  by  the  longus  colli  muscle,  the  pleura, 
and  some  cellular  tissue ;  finally,  on  the  left,  the  par  vagum  runs 
by  the  side  of  it,  and  the  serous  membrane  separates  it  from  the 
lung  until  near  the  first  rib :  it  is,  therefore,  much  deeper  seated 
than  the  arteria  innominata. 

The  left  subclavian  artery  ascends  parallel  to  the  preceding, 
from  which  it  is  separated  by  some  cellular  layers  only ;  this 
branch  lies  so  deep  that  it  is  almost  in  contact  with  the  pleura  in 
the  summit  of  the  thoracic  cavity ;  so  that  its  ligature,  previous 
to  its  passage  over  the  first  rib,  requires  the  greatest  precautions 
relatively  to  the  pleura. 

55 


434  OP    THE    CHEST, 


Sect.  2.  Of  the  Pectoral  Cavities. 

The  left  cavity  is  narrower  than  the  right,  on  account  of  the 
inclination  of  the  mediastinum  and  the  position  of  the  heart ;  but 
it  is  more  elongated,  because  the  diaphragm  does  not  ascend  so 
high  on  the  left  as  on  the  right.  Each  of  these  cavities  possesses 
three  parietes,  one  mediastinal,  one  diaphragmatic,  and  one 
costal ;  they  are  filled  by  the  lungs,  but  in  such  a  manner  that 
these  organs  descend  more  or  less,  according  to  the  side  which 
we  examine,  and  several  other  circumstances.  Thus,  on  the 
right  side,  the  liver,  in  the  natural  state,  keeps  the  diaphragmatic 
and  costal  parietes  applied  to  each  other  to  a  level  with  the  tenth 
rib  In  forcible  expirations,  M.  J.  Cloquet  has  demonstrated  that 
these  two  parietes  might  touch  each  other  even  as  high  as  the 
sixth  true  rib ;  so  that  the  lung  would  not  then  be  wounded  by  a 
weapon  wrhich  would  penetrate  through  one  of  the  first  five  in- 
tercostal spaces  (counting  from  below  upwards) ;  whilst,  during 
inspiration,  as  the  respiratory  organ  introduces  itself  between 
the  ribs  and  diaphragm  as  far  as  the  attachments  of  this  muscle, 
it  would  always  be  injured  in  penetrating  wounds  of  the  chest. 
In  the  first  case,  the  instrument  would  traverse  the  pleura  twice, 
then  the  diaphragm  and  peritoneum,  before  it  would  reach  the 
spleen  or  stomach  in  the  left  side  of  the  belly,  and  the  liver  in 
the  right ;  in  the  second,  the  lung  would  be  transfixed  before  the 
diaphragm  is  injured.  Superiorly,  in  the  summit  of  the  thorax, 
the  lung  is  separated  from  the  supra-clavicular  region  merely  by 
some  cellular  tissue  and  the  pleura ;  from  the  axilla,  by  the  first 
rib  and  the  internal  surface  of  the  four  following  ones:  there,  the 
space  is  narrower  and  rounded,  in  a  well-formed  subject ;  it  may 
be  much  more  so,  if  the  ribs  are  but  little  curved ;  the  respiratory 
organ  then  is,  as  it  were,  compressed  between  the  upper  part 
of  the  mediastinum,  the  vertebral  column,  and  the  costal  paries. 

The  pleura  which  lines  this  paries  sometimes  presents,  in  fat 
persons,  a  kind  of  adipose  appendages,  which  we  should  be  care- 
ful not  to  confound  with  the  sequelae  of  previous  inflammations. 
It  is  destined  to  favour  the  sliding  of  the  lung,  but  sometimes  be- 
comes more  or  less  adherent  to  this  organ ;  and  in  this  case,  the 
observations  which  we  have  just  made,  relative  to  the  ascending 


OF    THE    CHEST. 


435 


and  descending  movements  of  the  lungs,  are  no  longer  appli- 
cable. The  mechanism  of  the  formation  of  these  adhesions, 
which  is  at  present  better  understood  than  formerly,  deserves 
much  attention,  especially  in  relation  to  effusions.  In  fact,  the 
costal  and  visceral  sheets  of  the  serous  membrane  of  the  tho- 
rax (pleurcB  pulmonalis  et  costalis)  may,  in  consequence  of  pleu- 
ritis,  unite  throughout  their  whole  extent,  and  thus  obliterate  the 
cavity  which  separates  them  ;  but  they  may  also  be  separated,  to 
a  certain  extent,  by  the  pus  which  has  been  secreted,  whilst  they 
are  completely  agglutinated  throughout  the  remaining  portions, 
and  then  the  abscess  will  occupy  either  the  inferior,  superior,  or 
posterior  regions,  or  any  other  portion :  wherefore,  if  we  consid- 
ered the  operation  for  empyema  necessary,  we  must  not  refer  to 
the  gravitation  of  the  liquid  and  the  dependent  position  of  the 
thorax,  in  order  to  make  an  opening  into  this  cavity. 

The  same  thing  may  also  happen,  in  consequence  of  pene- 
trating wounds ;  but  if  the  extravasation  takes  place  before  in- 
flammation is  developed  and  adhesions  are  formed,  the  fluid  will 
generally  collect  in  the  sinuous  cavities  which  separate  the  dia- 
phragm from  the  ribs,  or  in  the  deep  gutter  which  exists  by  the 
side  of  the  spine,  if  the  patient  is  recumbent  on  the  back ;  that 
is  to  say,  that  the  matters  will  then  yield  to  the  laws  of  gravity. 
Therefore,  when  the  extravasation  is  sanguineous,  we  frequently 
observe  a  kind  of  stain,  or  ecchymosis,  at  the  lower  part  of  the 
dorsal  and  costal  regions ;  a  stain  w7hich  Valentine  considers  as  a 
diagnostic,  but  which  is  not  always  to  be  depended  on. 

If,  on  the  contrary,  the  collection  does  not  form  until  several 
days  after  the  wound  has  been  inflicted,  the  latter  will  still  con- 
tinue to  correspond  to  the  centre  of  the  effusion ;  and,  in  this 
case,  whenever  pus  fills  the  cavity,  if  the  collection  is  small  in 
quantity,  or  even  when  it  is  considerable,  if  it  be  sanguineous,  we 
should  take  care  how  we  make  a  counter-opening.  Some  mod- 
ern surgeons,  aUhe  head  of  whom  we  must  place  Baron  Larrey, 
consider  these  adhesions  of  great  importance.  They  think  that 
they  convert  these  depositions  into  simple  abscesses,  and  that  the 
surgeon  should  reduce  his  therapeutics  to  the  use  of  those  means 
which  will  be  most  likely  to  favor  the  absorption  of  the  effused 
liquids,  by  opposing,  as  much  as  possible,  the  admission  of  the 


436  OF  Tin; 

external  air  into  these  cavities,  because  this  gas  would  confer 
upon  the  extravasated  fluids  irritating  qualities,  which  would  hin- 
der them  from  passing  into  the  general  circulation. 

When  a  wound  penetrates  into  the  pectoral  cavity,  and  the 
lung  is  lacerated,  if  the  division  of  the  external  parts  is  exactly 
parallel  to  that  of  the  intercostal  muscles,  the  air  will  escape  out- 
wards, and  it  is  this  phenomenon  which  gave  rise  to  the  precept 
of  placing  a  lighted  candle  before  a  wound  of  the  chest,  in  order 
to  ascertain  if  it  is  penetrating.  If,  on  the  contrary,  the  openings 
of  the  different  wounded  organs  do  not  correspond,  the  gas  will 
pass  into  the  cellular  tissue  and  emphysema  will  follow.  This 
emphysema  is  itself  a  disease  which  may  become  very  serious, 
as  is  proved  by  the  observations  of  Mery,  Cleghorn,  Hunter,  etc. 
It  sometimes  extends  throughout  the  whole  body,  and  may  swell 
the  subject  to  an  enormous  size  ;  which  is  owing  to  the  commu- 
nication which  exists  between  all  the  cellular  layers.  Littre  and 
M.  Larrey  have  each  related  a  very  extraordinary  example  of 
this  kind.  We  also  conceive  that  if  the  pleura  and  lung  are  lace- 
rated without  the  skin  being  divided,  the  emphysema  will  take 
place  still  more  easily :  hence,  nothing  is  more  common  than  this 
accident  in  fractures  of  the  ribs,  of  which  it  constitutes  one  of  the 
most  certain  signs  ;  finally,  if  the  lung  is  lacerated,  notwithstand- 
ing the  thoracic  parietes  have  not  been  wounded,  there  will  be  in 
it  an  aeriferous  fistula  and  pneumo-thorax. 

The  pleura  costalis,  when  diseased,  sometimes  acquires  a  con- 
siderable thickness,  and  that,  in  two  different  ways :  in  one,  a 
greater  or  less  number  of  albuminous  layers  are  deposited  and 
organized  upon  its  internal  surface  ;  and  this  case  appertains  to 
pleurisies,  properly  so  called,  or  depends  upon  a  pulmonary  aftec- 
ti'»n.  It  would  be  useful  to  recollect  the  possibility  of  such  a 
disposition,  if  we  perform  the  operation  of  paracentesis  for  a  col- 
lection of  pus,  in  order  that  we  may  penetrate  more  deeply  so  as 
to  reach  the  cavity  ;  in  the  other,  which  generally  coincides  with 
an  external  disease  of  the  thorax,  it  is  the  sub-pleural  cellular  tis- 
sue which  becomes  thickened,  and  produces  in  certain  patients  a 
layer  resembling  bacon  (une  couche  lardacee),  of  a  line  or  more 
in  thickness.  Here,  it  is  a  species  of  barrier  which  nature  op- 
poses to  the  progress  of  the  disease,  and  upon  which  we  should 


«>F    THE    CHEST.  437 

calculate  when  we  are  obliged  to  operate  upon  the  exterior  of  the 
chest ;  a  barrier  which  also  repels  the  pus  of  deep  seated  abscess- 
es towards  the  skin,  and  prevents  them  from  opening  internally. 
There  are  numerous  facts  in  support  of  these  assertions.  We 
will  mention  but  one,  however,  which  we  witnessed  at  the  hospi- 
tal of  St.  Louis  in  18:21.  A  man  about  thirty  years  of  age  had  a 
large  fistulous  ulcer  covered  with  vegetations,  in  the  middle  of 
the  costal  region,  which  had  existed  two  years  :  one  rib  was  ca- 
rious, and  M.  Richeraud  was  obliged  to  remove  two  inches  of  its 
length.  This  celebrated  surgeon  was  apprehensive  of  penetrating 
into  the  serous  cavity ;  but  the  pleura  formed  a  thick,  hard  and 
opaque  wall,  which  permitted  him  to  remove  entirely  the  diseas- 
ed portion  of  bone,  and  this  laborious  operation  was  attended 
with  complete  success.  It  is  well  known  that  a  similar  disposi- 
tion existed  in  the  subject  from  whom  M.  Richerand  extirpated, 
by  a  bold  operation,  in  1818,  several  portions  of  the  ribs  together 
with  a  cancer. 

By  way  of  recapitulation :  vulnerant  bodies  can  only  reach  the 
heart,  by  traversing  the  chest  perpendicularly  to  its  axis,  above 
the  sixth  rib.  If  they  pass  through  the  fourth  intercostal  space, 
a  little  to  the  left,  they  will  fall  upon  the  base  of  the  right  ventri- 
cle, or  upon  the  left  auricle  ;  on  the  right,  they  would  wound  the 
ventricle  or  auricle  of  this  side ;  by  the  third  space,  they  would 
reach  the  trunk  of  the  aorta  or  of  the  pulmonary  artery,  and  the 
superior  vena  cava  on  the  right ;  by  the  second,  they  would  di- 
vide the  transverse  portion  of  the  arch  of  the  aorta,  or  the  prin- 
cipal branches  which  originate  from  it.  If  they  should  penetrate 
an  inch,  and  a  half  into  the  fifth  space,  at  the  union  of  the  sternal 
and  costal  regions,  they  would  strike  the  apex  of  the  heart.  If 
the  instrument  or  weapon  is  directed  from  the  costal  region  to- 
wards the  median  region  posteriorly,  it  will  hit  against  the  bodies 
of  the  vertebrae,  and  wound  the  great  sympathetic  nerve  or  tho- 
racic aorta.  But  it  is  proper  to  observe  that  these  w^ounds  are 
susceptible  of  pretty  numerous  variations,  relatively  to  the  sepa- 
ration of  the  ribs,  which  change  the  absolute  length  of  the  costal 
paries  and  of  the  pectoral  cavity  itself:  thus,  during  a  violent 
effort,  all  the  intercostal  spaces  are  enlarged  ;  it  is  the  same  in 
hydro-thorax.  In  pregnant  women,  dropsical  individuals,  new- 
born children,  etc.,  we  observe  a  contrary  disposition,  and  the 


438  OF    THE    CHEST. 

internal  organs  must  be  affected  in  different  points,  notwithstand- 
ing those  of  the  exterior  are  divided  in  the  same  manner.  Dis- 
eases also  occasion  changes  in  the  relative  position  of  the  organs, 
changes  which  affect  the  locality  of  the  injured  parts ;  so  also  do 
they  occasion  variations  in  the  form  of  the  chest  and  in  the  move- 
ments of  the  ribs ;  in  hydro-thorax,  for  example,  or  any  other 
effusion  into  one  side  only,  if  it  is  carried  to  a  great  extent,  this 
side  appears  longer,  more  prominent  and  bulging  than  the  other : 
when  this  effusion  disappears,  if  the  patient  recovers,  as  the  lung 
has  been  for  a  long  time  compressed  by  the  fluid,  it  will  not  re- 
sume its  natural  volume,  whence  it  follows  that  the  thoracic  paries 
goes,  if  I  may  so  express  myself,  before  it,  and  the  chest  thereby 
becomes  contracted  on  the  diseased  side.  M.  Laennec  has  very 
satisfactorily  explained  the  mechanism  of  this  phenomenon,  which 
then  persists  during  life. 

When  acute  pleurisy  exists,  whether  there  is  effusion  or  not, 
as  the  pain  prevents  the  contraction  of  the  muscles,  it  follows 
that  the  ribs  remain  imnioveable  in  the  direction  corresponding  to 
the  diseased  pleura,  arid  that  the  movements  of  expiration  and 
inspiration  are  increased  on  the  opposite  side.  If  the  lung  be- 
comes hepatized,  if  there  is  peripneumonia  with  or  without  costal 
pleurisy,  the  same  thing  may  equally  happen  ;  and  besides,  the 
respiratory  organ  actually  increases  in  volume  and  density,  in  con- 
sequence of  the  accumulation  of  fluids  within  it.  In  this  case, 
the  cavity  which  encloses  it  is,  if  I  may  so  say,  too  small  to  con- 
tain it ;  and,  as  the  ribs  resist  more  than  the  soft  parts  which  sep- 
arate them,  they  apply  themselves  upon  the  external  surface  of 
the  inflamed  lung,  producing  as  many  grooves,  more  or  less  dis- 
tinct, upon  this  organ.  This  last  peculiarity,  which  was  first 
pointed  out  by  M.  Broussais,  and  which  is  regarded  by  M.  Laen- 
nec as  a  very  difficult,  if  not  impossible  occurrence,*  has  pre- 
sented itself  twice  to  our  observation. 

The  walls  of  the  thorax  are  far  from  having  the  same  thickness 
in  all  their  points,  in  all  ages  or  in  all  individuals :  in  children 
they  are  comparatively  thin,  on  account  of  the  absence  of  fat 
and  the  small  size  of  the  muscles ;  hence  it  follows  that  in  early 
life  they  are  much  more  sonorous  than  after  puberty,  and  that  ii 

*  Auscultation  mediate,  etc.,  tome  Icr,  page  163. 


OP    THE    CHEST.  439 

we  resorted  to  the  method  of  Avenbrugger  for  exploring  the 
chest,  that  is  to  say  to  percussion  alone  in  order  to  establish  the 
diagnosis  of  its  diseases,  we  will  often  believe  that  the  lungs  are 
still  permeable  to  the  air,  though  their  hepatization  be  complete ; 
but  it  is  easy  to  rectify  this  error  by  means  of  the  stethoscope. 

In  the  sternal  region,  the  walls  are  thin  upon  the  median  line, 
where  the  sternum  is  only  covered  by  the  skin ;  they  are  also 
thin  upon  the  sides,  in  its  inferior  half,  where  the  cartilages  are 
only  separated  from  the  integuments  by  the  rectus  abdominis 
muscles ;  but,  in  general,  very  thick  laterally  in  the  superior  half, 
on  account  of  the  mamma  and  pectoralis  major  muscle. 

In  the  posterior  region,  they  are  extremely  thick  upon  the 
median  line,  and  even  as  far  as  the  angle  of  the  ribs,  on  account 
of  the  spinal  column  and  the  muscular  masses  which  fill  the  ver- 
tebral gutters.  Externally  and  superiorly,  the  shoulder  renders 
them  still  thicker  than  elsewhere ;  but  below  the  axilla,  and 
throughout  the  costal  region,  they  are  as  thin  as  in  the  inferior 
part  of  the  sternal  region. 

These  data,  important  relatively  to  wounds  of  the  thorax,  are  so 
likewise  when  we  wish  to  employ  percussion  or  apply  the  steth- 
oscope to  this  cavity :  then  we  should  also  recollect  the  exact 
relations  which  the  contained  viscera  bear  to  the  different  re- 
gions of  the  surface.  Thus,  notwithstanding  the  spongy  texture 
of  the  sternum,  and  the  slight  thickness  of  the  soft  parts,  below  the 
breast,  in  the  sternal  region,  the  chest  is  not  very  sonorous  in 
these  places,  at  least  on  the  left,  because  these  points  correspond 
to  the  heart  and  principal  vascular  trunks.  Auscultation  there- 
fore must  here  supercede  percussion,  in  the  examination  of  the 
affections  of  the  central  organs  of  the  circulation.  The  clavicle, 
being  never  covered  by  very  thick  soft  parts,  and  correspond- 
ing to  the  summit  of  the  lungs,  is  one  of  the  points  which  pre- 
sent the  greatest  advantages  for  percussion,  which  we  apply 
in  a  much  less  certain  manner  to  the  anterior  thoracic  portion  of 
the  axillary  region,  especially  in  women  and  fat  persons,  on  ac- 
count of  the  mammae.  But  this  last  situation  may  be  perfectly 
explored  by  means  of  the  cylinder,  which  equally  gives  more 
certain  results,  when  placed  upon  the  fossa  supra-spinata,  than  the 
method  of  the  celebrated  German  physician.  In  the  posterior 
region,  upon  the  lateral  convexities,  as  the  angles  of  the  ribs  are 


440  OF   THE    CHEST. 

only  covered  by  thin  muscles,  and  as  these  prominences  corres- 
pond internally  to  the  most  spongy  portion  of  the  respiratory 
organs,  we  derive  nearly  the  same  advantages  from  percussion 
and  auscultation :  the  same  might  be  said  in  relation  to  the  sides, 
if,  on  the  right,  the  liver  did  not  considerably  diminish  the  sono- 
rousness of  the  thorax,  in  the  inferior  part  of  the  costal  region ; 
whilst  on  the  left,  the  stomach,  pushing  up  the  diaphragm  more 
or  less,  enables  us  generally  to  derive  from  percussion  a  very 
clear  sound :  which  circumstances  might  induce  us  to  believe, 
in  the  first  direction,  that  the  lung  is  impermeable,  although  it 
may  be  sound,  and  in  the  second,  that  this  organ  is  in  the  natu- 
ral state,  when,  on  the  contrary,  it  is  more  or  less  disorganized. 
In  such  cases  we  must  also  have  recourse  to  the  stethoscope,  in 
order  to  avoid  error,  and  this  instrument  may  be  easily  applied 
to  all  the  points  of  the  costal  region,  even  as  high  as  the  third 
intercostal  space,  if  we  take  the  precaution  to  elevate  the  arm. 

Sect.  3.  Base  of  the  Thorax. 

This  part,  which  we  might  call  the  diaphragmatic  region  or 
wall  of  the  chest,  is  the  most  moveable  and  most  variable  in  the 
normal  state.  Formed  entirely  by  the  superior  surface  of  the 
diaphragm,  it  is  greatly  elevated  during  expiration,  and  more  of 
less  depressed  when  the  lungs  are  distended  with  air.  In  the 
first  case,  the  muscle  represents  two  rounded  eminences,  which 
ascend  in  the  thoracic  cavities,  a  little  higher  on  the  right  side 
than  on  the  left,  and  sometimes  to  the  seventh  or  sixth  rib.  In 
this  state,  those  physiologists  who  think  that  the  lungs  dilate  and 
contract  in  a  passive  manner,  suppose  that  the  diaphragm  is  in 
contraction,  and  that  it  is  this  muscle  which  expels  the  air.  But  it 
is  evident  that  the  effect  is  here  taken  for  the  cause,  and  that  this 
fleshy  membrane  merely  follows  the  lungs,  in  proportion  as  the 
gazeous  fluid  escapes  from  them  by  their  proper  action. 

In  the  second,  it  actually  contracts,  although  it  may  also  sink 
mechanically ;  its  fibres  straighten  themselves ;  it  pushes  the 
abdominal  viscera  downwards,  forwards,  and  slightly  towards  the 
right,  because  it  is  inclined  in  such  manner  as  to  look  a  little  in 
this  direction:  it  is  even  to  this  slight  inclination  of  the  dia- 
phragm that  we  may  attribute  the  greater  frequency  of  hernia; 


OP   THE    CHEST.  141 

on  the  right  side.  It  is  especially  when  we  make  any  great  ex- 
enion  that  it  contracts  in  a  decided  manner;  then  it  draws  upon 
the  ribs  to  which  it  is  attached,  tends  to  diminish  the  circle 
which  they  form,  and  maintains  them  more  or  less  solidly  fixed ; 
so  that  all  the  other  muscles  of  the  body  may  here  find  a  solid 
point,  either  by  their  direct  attachments,  or  by  their  actions  be- 
ing conveyed  to  it  through  the  medium  of  some  other  muscles. 
On  the  other  hand,  the  epiglottis  hermetically  seals  the  larynx, 
in  order  that  the  lungs,  distended  with  air,  may  exactly  fill  the 
cavity  of  the  chest,  and  keep  its  walls  suitably  separated.* 

This  region  presents  three  portions,  which  should  be  distinguished 
in  relation  to  their  functions :  we  find  in  the  first  place,  the  two 
lateral  portions,  completely  lined  by  the  pleura,  naturally  more  con- 
vex on  the  right  than  on  the  left,  inclined  backwards  and  upon  the 
sides,  and  which  correspond  to  the  muscular  portion  properly  so 
called :  it  is  to  these  two  portions  that  we  must  refer  what  has 
just  been  said  respecting  the  actions  of  the  diaphragm  ;  they  con- 
stitute the  internal  wall  of  the  sinuous  prolongation  of  each  cav- 
ity of  the  thorax,  the  vertical  diameter  of  which  they  alternately 
elongate  and  diminish.  Their  disposition,  moreover,  is  such,  that 
this  axis  or  diameter  is  shorter  anteriorly  than  posteriorly  and 
laterally. 

The  middle  portion  corresponds  to  the  central  aponeurosis,  and 
supports  the  heart ;  it  is  enclosed  in  the  mediastinum,  and  pre- 
sents anteriorly,  behind  the  xiphoid  cartilage,  the  cellular  com- 
munication which  exists  between  the  abdomen  and  thorax ; 
more  posteriorly,  the  two  pleurae,  which  are  very  close,  but  not 
completely  applied  to  each  other.  Next  comes  the  great  cir- 
cular portion,  entirely  fibrous,  from  the  circumference  of  which 
the  pericardium  seems  to  originate,  and  which  is  perforated  on 
the  right  by  an  irregularly  square  foramen,  through  which  the 
inferior  vena  cava  passes ;  so  that  this  vessel  cannot  be  compres- 
sed in  any  manner  by  the  contractions  of  the  diaphragm ;  more 
posteriorly  still,  the  pleurae  again  approximate,  and  are  even  in 
contact  upon  the  fore  part  of  the  oesophagus,  which  is  consid- 
erably inclined  to  the  left ;  finally,  we  find  in  the  diaphragmatic 

*  M.  Isidore  Bourdon.    Mcmoire  cit6, 

56 


442  OF    THE    CHEST. 

extremity  of  the  posterior  separation  of  the  mediastinal  septum, 
a  hiatus  for  the  transmission  of  the  aorta,  through  which  the 
thoracic  duct  also  passes,  in  the  same  way  that  the  nervi  vagi 
penetrate  into  the  belly  by  the  ossophageal  aperture ;  the  great 
and  lesser  splanchnic  nerves,  which  result  from  the  union  of  six 
or  seven  filaments  derived  from  the  last  corresponding  ganglions 
of  the  great  sympathetic.  This  portion  of  the  diaphragmatic 
wall  is  almost  immoveable  when  the  lateral  parts  are  elevated 
or  depressed  ;  and  we  conceive  that,  if  it  had  been  otherwise,  the 
action  of  the  heart  would  have  been  disturbed  at  every  instant. 
It  is  almost  plane,  being  but  slightly  inclined  from  before  back- 
wards and  from  above  downwards :  whence  it  follows  that  the 
posterior  mediastinal  space  is  longer  than  the  anterior. 

Sect.  4.  Summit  of  the  Thorax. 

It  comprises  the  superior  opening  of  the  chest  and  the  numer- 
ous organs  which  traverse  it.  The  osseous  circle  has  the  form 
of  an  ellipse,  the  posterior  part  of  which  seems  as  if  it  had  been 
forcibly  pushed  towards  the  anterior.  It  is  constituted,  ante- 
riorly, by  the  supra-sternal  notch,  which  is  rendered  much  deeper 
by  the  prominence  which  the  clavicles  form  upon  the  sides; 
posteriorly,  by  the  body  of  the  first  dorsal  and  of  the  seventh 
cervical  vertebrae;  externally,  by  the  concave  margin  of  the 
first  rib.  We  may  observe  that  this  opening  is  neither  upon  an 
even  nor  horizontal  plane.  Its  anterior  notch  makes  it  appear 
more  or  less  elevated  posteriorly ;  so  that  several  organs  deeply 
situated  in  this  direction  are  already  in  the  thorax,  whilst,  more 
superficially,  they  would  still  be  in  the  infra-hyoideal  region. 
On  the  outer  side  of  the  median  line,  the  sterno-clavicular  ar- 
ticulation gives  to  it  a  greater  elevation,  and  thus  affords  greater 
protection  to  the  important  organs  which  are  situated  behind  it. 
Upon  the  sides,  it  is  again  depressed,  on  account  of  the  inclina- 
tion outwards  of  the  superior  aspect  of  the  ribs. 

Let  us  now  examine  the  order  of  superposition  of  the  organs, 
and  their  relative  dispositions  in  the  summit  of  the  chest :  by 
comprising  in  it  the  constituent  parts,  we  find; — 1st  the  skin; 
2d,  the  sub-cutaneous  cellular  and  fibrous  layer ;  3d,  the  top  of 


OF   THE    CHEST. 


443 


the  sternum,  the  origin  of  the  sterno-mastoid  muscle,  the  inter- 
clavicular  ligament,  the  sterno-clavicular  articulation,  the  costo- 
clavicular  ligament,  the  cartilage  of  the  first  rib,  and  the  termin- 
ation of  the  two  laminae  of  the  fascia  cervicalis :  this  plane  is 
completed  posteriorly  by  the  origin  of  the  sterno-hyoid  and  ster- 
no-thyroid  muscles,  which  descend  as  far  as  on  a  level  with  the 
first  intercostal  space,  behind  the  sternal  notch  and  the  articula- 
tion ;  4th,  a  thin,  but  pretty  dense  cellular  layer ;  upon  the  same 
plane,  on  the  left,  the  subclavian  vien  and  the  terminations  of 
the  internal  and  external  jugulars  ;  in  the  middle,  the  subclavian 
vein  still,  the  termination  of  the  thyroideal  veins,  the  thymus ;  on 
the  right,  the  junction  of  the  left  and  right  subclavian  veins,  and  of 
the  internal  and  external  jugulars,  in  order  to  form  the  superior 
vena  cava ;  5th,  a  very  compact  fibro-cellular  layer,  which  sepa- 
rates the  veins  from  the  arteries ;  behind  this  layer,  and  from  right 
to  left,  the  termination  of  the  arteria  innominata,  the  origin  of  the 
common  carotid  and  subclavian  arteries,  very  close  to  the  bones ; 
the  internal  mammary,  which  runs  towards  the  posterior  surface 
of  the  sternum,  accompanied  by  its  two  veins ;  the  thyroid  ar- 
tery of  Neubauer,  when  it  exists ;  the  vertebral,  when  it  ori- 
ginates from  the  aorta ;  the  left  carotid ;  more  deeply,  the  sub  - 
clavian,  giving  off  the  internal  mammary  of  this  side ;  the  par- 
vagum  and  phrenic  nerves  placed,  on  the  right,  before  and  a  lit- 
tle to  the  outer  side  of  the  arteria  innominata ;  on  the  left,  be- 
fore, and  somewhat  remote  from  the  subclavian  artery  ;  6th,  the 
body  of  the  trachea,  enveloped  in  a  dense  and  compact  fibro- 
cellular  tissue ;  externally,  some  lymphatic  glands,  the  recurrent 
nerves  ;  7th,  the  oesophagus,  in  the  middle,  and  slightly  passing 
beyond  the  trachea  on  the  left ;  externally,  numerous  filaments 
of  the  great  sympathetic  nerve ;  the  origins  of  the  vertebral, 
superior  intercostal  and  transverse  cervical  arteries ;  their  col- 
lateral veins  ;  8th,  the  longus  colli  and  scalenus  anticus  muscles, 
which  leave  between  them  a  triangular  space  with  its  base 
downwards,  in  which  we  see  the  vertebral  artery  and  vein,  a 
nervous  plexus  derived  from  the  great  sympathetic,  and  this 
nerve  itself;  under  the  head  of  the  rib,  the  inferior  cervical  gan- 
glion ;  9th,  lastly,  the  bodies  of  the  vertebrae,  less  prominent, 
but  of  rather  greater  transverse  extent  than  in  th^  chest  prop- 


444  OF    THE    CHEST. 

erly  speaking ;  the  first  costo-vertebral  articulation ;  sometimes 
a  costiforme  prolongation,  which  surmounts  the  transverse  pro- 
cess of  the  seventh  vertebra  of  the  neck ;  the  first  rib  and  the 
anterior  branch  of  the  first  dorsal  nerve,  which  goes  to  unite 
with  the  last  of  the  cervical  region. 

From  this  simple  enumeration,  it  is  easy  to  foresee  the  danger 
arising  from  wrounds  penetrating  into  the  summit  of  the  chest, 
and  how  it  is  that  fluids  extravasated  or  accumulated  in  the  mid- 
dle and  lateral  regions  of  the  neck,  may  extend  behind  the  ster- 
num, before  the  spine,  or  follow  the  vessels,  and  diffuse  them-* 
selves  in  the  anterior  and  posterior  mediastinal  spaces  without 
penetrating  into  the  cavities  of  the  pleurse.  We  can  also  con- 
ceive the  symptoms  wrhich  may  arise  from  the  exostoses  occa- 
sionally produced  by  syphilis  upon  the  fore  part  of  the  vertebrae, 
and  which  still  more  frequently  grow  from  the  clavicle  and  even 
the  sternum ;  from  luxations  of  the  clavicle  backwards,  when 
they  exist ;  in  short,  from  tumours  of  any  kind,  by  the  prssurc 
which  they  would  exercise  upon  the  trachea,  oesophagus,  veins, 
arteries  or  nerves. 

If  we  now  take  up  the  consideration  of  the  order  of  superposi- 
tion of  the  parts  in  another  point,  we  will  find  some  differences, 
with  which  the  surgeon  should  be  well  acquainted.  Immedi- 
ately above  the  heart,  for  example,  which  corresponds  to  the  first 
two  intercostal  spaces  and  the  upper  piece  of  the  sternum,  we 
find,  1st,  the  skin  ;  2d,  the  cellulo-adipose  layer,  a  fibro-cellulous 
lamina,  the  pectoralis  major  muscle  ;  3d,  the  sternum,  the  car- 
tilages, the  intercostal  muscles,  including  the  external  branches 
of  the  internal  mammary  artery;  the  trunk  of  this  artery 
coasted  by  twro  veins,  and  enveloped  by  a  cellular  layer  which 
separates  it  from  the  pleura ;  4th,  in  the  middle,  the  superior 
triangle  of  the  anterior  separation  of  the  mediastinum,  filled  by 
cellular  tissue,  lymphatic  glands  and  fat ;  the  pleura  upon  the 
sides ;  5th,  a  prolongation  of  the  pericardium,  and  of  the  thy- 
mus  in  children ;  6th  the  superior  vena  cava  and  the  azygos. 
which  turn  over  the  right  bronchus ;  the  trunk  of  the  aorta  and 
its  transverse  arch ;  the  origins  of  the  arteria  innominata,  left 
carotid  and  left  subclavian  arteries ;  the  pulmonary  artery,  at 
first  before  the  aorta,  afterwards  behind  it  and  to  the  right :  it? 


OF   THE    CHEST.  445 

two  branches  and  the  remains  of  the  ductus  arteriosus,  which 
unites  the  left  pulmonary  artery  to  the  aorta,  below  the  curva- 
ture of  the  latter  ;  the  phrenic  nerve,  upon  the  aorta  on  the  left, 
the  vena  cava  on  the  right,  and  upon  the  fore  part  of  the  root  of 
the  lungs,  on  both  sides ;  the  nerves  of  the  eighth  pair,  disposed 
like  the  phrenic,  except  that  they  pass  behind  the  pulmonary 
roots  ;  the  cardiac  ganglion,  placed  between  the  transverse  arch 
of  the  aorta  and  the  pulmonary  arteries ;  the  nerves  which  this 
ganglion  receives  and  the  plexus  which  depart  from  it;  some 
fibro-cellular  tissue,  continuous  with  the  pericardium  and  the 
vascular  sheaths  of  the  neck ;  7th,  the  auricles  and  pulmonary 
veins ;  the  termination  of  the  trachea  and  the  commencement  of 
the  bronchi ;  next,  the  root  of  the  respiratory  organs,  which  is 
composed  from  before  backwards  and  from  below  upwards,  of  the 
phrenic  nerve,  the  veins,  the  arteries,  the  first  division  of  the  bron- 
chi, the  plexus  of  the  par  vagum  ;  8th,  the  bronchial  vessels,  the 
oesophagus,  thoracic  duct,  the  vena  azygos  before  it  rises  upon 
the  right  bronchus ;  the  commencement  of  the  thoracic  aorta, 
after  it  has  turned  over  the  left  bronchus ;  9th,  the  intercostal 
arteries  and  veins,  the  venae  azygos  and  demi-azygos ;  the  great 
sympathetic  nerve  ;  10th,  and  lastly,  the  vertebral  column,  cov- 
ered by  the  origin  of  the  longus  colli  muscle,  and  the  ligamen- 
tous  parts. 

Still  lower  these  relations  are  less  complex.  Behind  the  ster- 
num, we  see  :  1st,  the  inferior  triangle  of  the  sub-sternal  separa- 
tion of  the  mediastinum,  an  abundance  of  cellular  tissue ;  2d,  the 
pericardium,  formed  of  two  laminae  in  the  middle,  and  of  three 
at  the  sides,  on  account  of  the  pleura  which  is  applied  to  it ;  3d, 
a  space  which  separates  the  heart  from  its  envelope ;  4th,  the 
apex  of  the  heart,  its  right  ventricle,  the  auricles :  the  right  more 
anteriorly,  the  left  more  posteriorly ;  5th,  the  left  ventricle,  the 
posterior  part  of  the  auricles,  the  termination  of  the  pulmonary 
veins  and  inferior  cava ;  6th,  another  space,  which  separates  the 
heart  from  the  pericardium  behind  ;  7th,  the  pericardium,  dispo- 
sed as  anteriorly ;  8th,  the  approximated  pleurae ;  9th,  the  oeso- 
phagus and  nervi  vagi ;  10th,  the  aorta,  &c. 

When  the  viscera  of  the  thorax  are  removed,  its  cavity  presents 
four  portions  or  regions.  The  anterior  is  inclined  forwards,  or  ra- 


446  OF    THE    CHEST. 

therit  forms  a  curve,  the  concavity  of  which  looks  backwards  and 
downwards :  at  puberty  it  elongates  more  than  either  of  the  others; 
which  is  owing  to  the  rapid  developement  of  the  sternum  at  this 
epoch.  The  posterior  wall  is  much  longer,  and  proportionally  still 
more  so  in  infancy  than  in  the  adult,  because  the  vertebral  column 
which  forms  it  is  already  very  long  at  birth,  whilst  the  sternum, 
on  the  contrary,  is  very  short :  whence  it  follows  that  the  abdo- 
men then  seems  to  have  considerable  dimensions  anteriorly, 
whilst  posteriorly  the  relations  of  this  cavity  with  the  chest  are 
nearly  the  same  that  they  always  are.  This  wall  is  concave  be- 
fore, and  not  simply  inclined  backwards.  As  it  is  formed,  1st, 
by  the  bodies  of  the  dorsal  vertebrae  upon  the  median  line,  it 
there  represents  a  sort  of  rounded  crista,  which  actually  consti- 
tutes the  posterior  part  of  the  mediastinal  septum ;  2d,  by  the 
angular  portion  of  the  ribs  upon  the  sides,  where  there  are  two 
deep  gutters  in  which  the  lungs  principally  are  lodged :  But  these 
peculiarities  are  more  striking  towards  the  adult  period,  and  in 
well-formed  subjects.  In  very  young  children,  in  fact,  the  bod- 
ies of  the  vertebrae  seem  to  be  thrown  backwards,  because  the 
angle  of  the  ribs  is  not  yet  developed.  Sometimes  this  disposi- 
tion persists  after  puberty,  in  which  case  the  lungs,  less  free,  are 
impeded  in  their  motions,  and  more  disposed  to  chronic  diseases. 
The  chest  appears  narrow  in  these  persons ;  the  shoulders  pro- 
ject backwards  and  the  sternum  forwards ;  so  that  the  central 
organs  of  the  circulation  move  more  freely,  on  account  of  the 
enlargement  of  the  antero-posterior  diameters  of  the  thoracic 
cavity. 

The  lateral  wall  is  the  longest ;  posteriorly,  it  is  concave  trans- 
versely, and  in  a  regular  manner  also,  from  above  downwards,  in 
many  subjects,  among  others  in  those  females  who  are  in  a  habit 
of  wearing  tight  corsets. 

In  consequence  of  the  difference  in  the  curvature  and  length 
of  the  thoracic  parietes,  the  base  and  summit  of  this  cavity  are 
inclined  in  opposite  directions,  that  is  to  say,  that  the  superior 
aperture  is  depressed,  whereas  the  inferior  is  raised,  in  the  same 
manner  as  the  two  straits  of  the  pelvis  ;  so  that  a  line,  dropped 
perpendicularly  in  the  centre  of  the  former,  would  fall  upon  the 
base  of  the  dorsal  column,  and  that,  if  this  line  was  let  fall  from 


OP   THE    CHEST.  447 

the  centre  of  the  second,  it  would  strike  upon  the  body  of  the 
first  vertebrae  of  the  back.  It  also  follows  that  the  vertical  axis 
of  the  chest  is  oblique  from  above  downwards,  from  behind  for- 
wards, and  even  from  left  to  right,  on  account  of  the  lateral  cur- 
vature in  the  middle  of  the  dorsal  column.  With  respect  to  the 
transverse  dimensions,  they  increase  in  a  prompt  and  gradual 
manner  as  far  as  the  seventh  rib ;  in  descending  afterwards,  they 
also  enlarge,  hut  slightly ;  in  some  persons  they  remain  the  same 
as  they  were  higher  up  ;  and  in  others,  they  are  diminished  in  a 
very  striking  manner. 


END    OF   THE    FIRST    VOLUME. 


449 


EXPLANATION  OF  THE  PLATES. 

VOL.  I. 

PLATE  I. 

FIGURE  1,  Representing  the  Anterior  Regions. 

1  1  Frontal  Regions,  viewed  in  front,  separated  from  each  other 

by  the  median  line. 

2  2  Parietal, 
555  Orbitary, 

44444  Parotideal, 
666  Massetcric, 

7  7  Nasal, 

888  Zygomato-Maxillary, 
999  Genial, 

37  37  Labial, 

38  38  Mental, 

10  10  10  Supra- Hyoidal, 
1111  Infra-Hyoidal, 
12  12  Supra-  Clavicular, 

40  40  Sub-Clavicular, 

41  41  Anterior  Brachial, 

42  42  Regions  of  the  Fold  of  the  Arm. 

43  43  Anterior  Anti-Brachial  Regions. 

44  44  Anterior  Regions  of  the  Wrist. 
45  Palmar  Region  of  the  Hand. 

21  21  Sternal  Region. 
2323  Epigastric. 
24  24  Umbilical. 
2525  Hypogastric, 

39  39  Pubic, 

46  46  Inguinal  Regions, 
28  28  Anterior  Crural, 

29  29  29  Regions  of  the  Knee. 

47  47  Anterior  Regions  of  the  Legs. 
31  31  31  External  Tibial  Regions. 

48  48  Internal  Malleolar. 

57 


450  EXPLANATION  OF  THE  PLATES. 

FIG.  3,  Representing  the  Posterior  Regions. 

3  3  Occipital  Regions. 

13  13  13  Posterior  Region  of  the  Neck.  In  order  to  study  this  region., 

the  reader  should  make  an  abstraction  of  the  perpendicular 
line  which  divides  this  region  into  two. 

14  14  14  Posterior  Region  of  the  Shoulder. 

15  15  15  15  Posterior  Brachial  Regions. 

16  16  16  16  Region  of  the  Elbow. 

17  17  17  17  Posterior  Anti-Brachial  Regions. 

18  18  18  18  Po  terior  Regions  of  the  Wrist. 

19  19  19  19  Dorsal  Regions  of  the  Hand. 

35  Dorsal  Region  of  the  Thorax, 

36  Lumbar  Region. 

20  20  20  20  20  Costal  Regions  and  Hypochondria, 
22  22  22  22  22  Regions  of  the  Flanks. 
26  26  26  26  Gluteal  Regions. 

27  27  27  Posterior  Crural  Regions. 

30  30  30  Popliteal  Regions. 

32  32  32  Posterior  Regions  of  the  Leg. 

33  33  33  33  33  External  Malleolar  Regions. 

34  34  34  34  34  Dorsal  Regions  of  the  Foot. 

FIG.  2.  The  same  numbers  indicate  the  same  regions  viewed  laterally 

PLATE  II. 

This  Figure  represents  a  vertical  section  of  the  head  and  of  the  anterior  wall  of  the 
larynx,  but  in  such  a  manner  that  the  latter  is  reflected  upon  the  right  side,  so  as  t(* 
present  itself  in  front. 

1  Portion  of  the  Cranial  Cavity. 

2  Fossa  Cerebelli  of  the  Cranium,  lined  by  the  dura  mater. 

3  Portion  of  the  Tentorium  Cerebelli,  raised  by  a  hook. 

4  Prolongation  of  the  medulla  in  the  spinal  canal. 

5  Sphenoidal  Sinus,  in  which  we  see  the  extremity  of  a  stylet, 

and  which  communicates  in  the  superior  meatus  of  the 
nasal  fossa?. 

6  Frontal  Sinus,  equally  containing  a  stylet,  and  opening  into 

the  middle  meatus. 

7  Superior  Cornet,  \ 

8  Middle  or  Ethmoidal  do.  5  (Turbinated  bones) 

9  Maxillary  or  inferior  do.  J 

10  Superior  meatus,  leading  into  the  sphenoidal  sinus 

11  Middle  meatus,  broader  anteriorly,  narrower  posteriorly, 

where  it  no  longer  forms  but  a  gutter,  which  conducts  into 
the  upper  part  of  the  pharynx,  above  the  Eustachian 
trumpet.  It  is  in  this  rneatus  that  the  orifices  of  the  frontal 
and  maxillary  sinuses  are  observed,  each  traversed  by  a 
stylet. 


EXPLANATION  OF  THE  PLATES.  451 

12  Inferior  meatus. 

13  Stylet  introduced  into  the  sinus  of  the  sphenoid. 

14  Another  stylet  which  has  passed  through  the  entire  length  oi 

the  external  wall  of  the  inferior  meatus,  in  order  to  place 
itself  in  the  guttural  canal  of  the  ear. 

15  Third  stylet,  engaged  in  the   antrum  of  Hygmore :   we 

may  perceive  that  the  opening  of  this  sinus  seems  to  be 
situated  in  a  species  of  excavation,  and  more  approximated 
to  the  middle  than  to  the  inferior  cornet. 

16  Fourth  stylet  which  ascends  into  the  frontal  sinus  by  the 

middle  meatus. 

17  The  fifth,  engaged  in  the  nasal  canal,  under  the  anterior 

part  of  the  maxillary  cornet,  where  is  observed  a  kind  of 
infundibuliform  depression. 

These  last  four  stylets  are  enclosed  in  the  left  aperture  of 
the  nose,  the  lobule  of  which  is  preserved,  as  well  as  the 
pedicle  which  fixes  it  to  the  nasal  spine. 

18  Stylet  introduced  into  the  Parotid  duct  by  its  buccal  orifice, 

opposite  to  the  interval  which  separates  the  third  from  the 
fourth  molar  tooth. 

19  Interior  of  the  pharynx,  which  curves  upwards  and  forwards, 

in  order  to  continue  itself  with  the  nasal  fossse :  its  right 
half  is  reflected  backwards  and  downwards,  in  order  to 
show  the  posterior  wall. 

20  Pharyngeal  orifice  of  the  Eustachian  trumpet. 

21  Left  half  of  the  uvula,  drawn  downwards  and  forwards  by 

a  hook,  in  order  to  render  the  pillars  of  the  velum  palati 
tense. 

22  The  Tonsil. 

23  Posterior  or  pharyngeal  pillar  of  the  velum  palati. 

24  Lingual  or  anterior  pillar. 

25  Vertical  section  of  the  palatine  vault. 

26  Left  portion  of  the  palatine  cavity. 

27  Internal  wall  of  the  left  cheek,  presenting,  posteriorly,  the 

anterior  border  and  a  portion  of  the  internal  face  of  the 
coronoid  apophysis  of  the  lower  jaw,  enveloped  by  the 
mucous  membrane. 

28  Left  half  of  the  dorsum  of  the  tongue,  slightly  drawn  for- 

wards and  inclined  to  the  right. 

29  Perpendicular  section  of  the  inferior  maxillary  bone  and  of 

the  parts  which  compose  the  supra-hyoidal  region  upon 
the  median  line :  this  section  prolongs  itself  upwards  with 
that  of  the  tongue,  and  downwards  with  that  of  the  an- 
terior part  of  the  larynx,  the  right  half  of  which  is  drawn 
backwards. 

30  Inferior  part  of  the  pharyngeal  cavity,  at  the  moment  when 

it  passes  behind  the  arythenoid  cartilages,  in  order  to 
continue  itself  with  the  oesophagus. 
31  31  Great  Cornua  of  the  thyroid  cartilage. 


EXPLANATION    OF    THE    PLATES. 

3232  Ventricles  of  the  larynx,  circumscribed  by  the  inferior  and 

superior  cordae  vocales. 
33  Interior  of  the  Laryngeal  cavity. 
34  34  Hooks  which  keep  separate  the  two  halves  of  the  larynx,  in 

order  to  show  the  internal  surface. 
35  Inferior  portion  of  the  neck. 

PLATE  III. 

This  figure  represents  the  fore  part  of  the  neck,  separated  from  the  head  and  the  tho- 
rax: it  is  relative  to  the  details  of  the  infra-hyoidal  region. 

1  1  Reflected  flap  of  the  subcutaneous  layer,  continuous  by  its 

base  with  the  similar  layer  of  the  supra-hyoidal  region. 

2  2  Another  portion  of  the  teguments,  likewise  reflected. 
3333  Superior  and  lateral  parts  of  the  neck,  and  the  commence- 
ment of  the  head,  in  the  natural  state. 

4  Left  Sterno-mastoid  Muscle,  reflected  outwards  by  (5)  a  hook, 
in  order  to  expose  the  organs  which  it  covers. 

6  Right  Sterno-mastoid  Muscle,  in  its  natural  position,  or 

slightly  drawn  outwards. 

7  Sterno-hyoid  Muscle. 

8  Sterno-thyroid  Muscle. 

9  Omo-hyoid  Muscle. 

10  Internal  Jugular  Vein. 

11  Common  Carotid  Artery. 

12  External  Carotid  Artery. 

13  Internal  Carotid  Artery. 

14  External  Jugular  Vein,  or  rather,  anterior  jugular  vein  in- 

osculating with  the  internal  jugular  vein  towards  the  mid- 
dle of  its  length,  and  following  the  internal  margin  of  the 
sterno-mastoid  muscle. 

15  Descending  branch  of  the  hypogiossal  nerve    (descendens 

noni),  a  little  nearer  the  median  line  than  usual,  in  this 
subject. 

16  Pneumo-gastric  nerve  (par  vagum),  which  communicated 

here  with  the  ramus  descendens  noni,  and  of  which  one 
branch  passed  transversely  between  the  primitive  carotid 
artery  and  the  omo-hyoideus  muscle. 

17  Inferior  Thyroid  Veins. 

18  Superior  Thyroid  Arteries. 

19  Crico-thyroid  branch,  furnished  by  the  preceding  artery. 

20  Another  branch  of  the  superior  thyroid,  and  which  pene- 

trates into  the  thyroid  gland,  by  passing  upon  the  ante- 
rior face  of  the  cricoid  cartilage. 

21  Thyroid  Cartilage. 

22  €rico-thyroid  membrane. 

23  Cricoid  Cartilage,  covered  by  its  two  small  muscles. 

24  Thyroid  Gland  slightly  developed. 


EXPLANATION  OP  THE  PLATES.  453 

25  Trachea-Arteria. 

26  Anterior  Jugular  Vein,  enclosed  by  the  laminae  of  the  deep 

sheet  of  the  cervical  aponeurosis,  which  conceals  on  this 
side  the  sterno-hyoid  and  sterno-thyroid  muscles,  and 
which  passes  behind  the  sterno-mastoid. 

7  9  4  14  Omo-tracheal  triangle,  limited  above  by  the  scapulo-hyoid 
muscle ;  below  by  the  sterno-mastoid ;  internally,  by  the 
sterno-hyoid  and  the  trachea-arteria,  and  in  which  we 
may  tie  the  primitive  carotid  artery. 

4  9  18  Omo-hyoid  triangle,  circumscribed  by  the  sterno-mastoid 
externally;  by  the  omo-hyoideus  internally;  by  the  os 
hyoides  superiorly,  and  in  which  we  may  easily  apply  a 
ligature  upon  the  common,  internal,  and  external  carotid 
arteries,  and  the  superior  thyroid. 

PLATE  IV. 

In  order  that  the  objects  represented  in  this  figure  may  be  fully  comprehended,  it  is  neces- 
sary to  remark,  that  the  shoulder  is  firmly  depressed,  in  order  to  place  in  vieio  the  sub- 
clarian  vessels,  and  that  all  the  parts  are  in  the  position  which  is  given  them,  when 
about  to  practise  the  ligature  of  the  subclavian  artery. 

1  1  Occiput  thrown  a  little  backwards. 

2222  Flaps  of  skin  lined  by  its  subcutaneous  layer,  raised  behind 
the  ear,  and  turned  down  upon  the  lore  part  of  the  chest. 
3  Lobule  and  part  of  the  pavilion  of  the  ear. 
444  Perpendicular  section  of  the  skin  upon  the  posterior  limits 

of  the  region. 
5  5  Section  of  the  clavicular  portion  of  the  trapezius  muscle. 

6  Commencement  of  the  shoulder. 

7777  Sterno-Mastoid  Muscle,  showing  between  its  two  roots  a 
small  excavation  which  corresponds  to  the  brachio-cepha- 
lic  trunk. 

8  Flap  of  adipo-cellular  tissue,  preserved  upon  the  external 
face  of  the  preceding  muscle,  and  traversed  by  the  two 
nervous  branches  of  the  cervical  plexus,  which  go  to  the 
fore  part  of  the  neck. 

9  10  Splenius  Cervicis  and  Lev.  Ang.  Scapulas  muscles. 
1111  Scalenus  posticus  muscle,  formed  of  two  bundles. 

12  Scalenus  anticus  muscle. 
13  13  Omo-hyoideus  muscle. 

14  Subclavian  Artery  on  the  outer  side  of  the  scalenus  anticus. 

1 5  Termination  of  the  internal  jugular  vein. 

16  Termination  of  the  subclavian  vein. 

17  External  jugular  vein,  reflected  and  drawn  down  with  the 

integuments. 
18  18  Acromio-clavicular,  or  principal  vein  of  the  shoulder. 

19  Small  anormal  muscle,  forming  an  arch,  fixed  by  its  two  ex- 
tremities to  the  clavicle. 


454  EXPLANATION  OF  THE  PLATES. 

20  Ascending  cervical  artery. 

21  Internal  mammary  artery. 
22  22  Posterior  scapulary  artery. 

23  23  23  Nerves  of  the  Brachial  Plexus. 

24  Supra-clavicular  branch  of  the  cervical  plexus. 

25  Phrenic  Nerve. 

26  Spinal  Nerve,  confounded  with  a  branch  of  the  cervical 

plexus. 
27  27  27  Sub-mental  branches  of  the  cervical  plexus. 

28  Sub-mastoid  Nerve,  or  posterior  auncular  of  the  cervical 

plexus. 

29  Spinal  Nerve,  which  passes  behind  the  sterno-mastoid,  in- 

stead of  traversing  it. 

30  Portion  of  the  grooved  director  (sonde  cannel^e),  which  raises 

the  subclavian  artery,  14,  on  the  outer  side  of  the  scalenus 
anticus,  upon  the  first  rib,  depressing  the  supra-clavicular 
nerves. 

31  Sonde  Cannette,  introduced  under  the  same  artery,  between 

the  origin  of  the  internal  mammary,  vertebral  and  ascend- 
ing cervical  branches,  on  the  one  part,  and  the  internal  bor- 
der of  the  scalenus  anticus,  on  the  other. 

32  The  same  instrument,  passed  under  the  common  trunk  of 

the  thyroid  and  ascending  cervical  arteries,  and  also  rais- 
ing the  phrenic  nerve. 
21313197  Omo-clavicular   Triangle,  limited  by  the  omo-hyoideus  and 

sterno-mastoid  muscles,  and  the  clavicle. 

4  4  4  7  7  27  27  13  13  Omo-trapezien  Triangle,  circumscribed  by  the  sterno-mastoid, 
trapezius,  and  omo-hyoideus  muscles. 

22  Omo-clavicular   Triangle,  divided  into  two  portions  by  the 

scalenus  anticus  muscle. 

PLATE  V. 

In  this  figure  the  arm  is  slightly  removed  from  the  trunk;  the  sM,n,  the  subcutaneous  lay- 
er, the  cellular  tissue  and  the  lymphatic  glands  are  removed. 

1  Portion  of  the  internal  face  of  the  arm. 

2  Hairs  of  the  axillary  excavation. 
333333  Limits  of  the  region. 

4  4  Flaps  of  the  pectoralis  major  muscle,  one  externally  upon  the 
fore  part  of  the  deltoid,  the  other  internally  and  inferiorly 
upon  the  chest. 

5  Pectoralis  minor  muscle. 

6  Anterior  portion  of  the  deltoid  muscle. 

7  Subclavius  muscle. 

8  Coraco-brachialis  muscle. 

9  Lateral  portion  of  the  thorax. 
10  Anterior  part  of  the  clavicle. 


EXPLANATION  OF  THE  PLATES.  455 

11  Coraco-clavicular  aponeurosis,  covering  the  eubclavius  mus- 

cle :  we  only  see  here  the  internal  and  superior  portion  of 
this  aponeurosis,  the  rest  having  been  removed  in  order  to 
expose  the  vessels  and  nerves  to  view. 

12  Sonde  Cannelte  raising  the  axillary  artery  at  the  place  where 

we  should  apply  the  ligature  upon  the  vessel  in  the  clavi- 
pectoral  triangle. 

13  13  Axillary  Vein. 

14  14  Cephalic. 

15  15  Axillary  Artery. 

16  16  16  16  Median  Nerve  and  its  two  roots  which  embrace  the  artery. 
1717  Musculo-cutaneous  nerve,  running  along  the  internal  border 
of  the  coraco-brachialis  muscle,  from  which  a  slice  has 
been  removed  parallel  to  the  fleshy  fibres  in  order  to  give 
a  better  view  of  the  nervous  cord. 

18  18  Ulnar  Nerve,  still  very  close  to  the  artery. 

19  19  Internal    cutaneus,  separated  from  the  preceding  by   the 

axillary  vein. 

20  Posterior  Thoracic  Nerve,  concealed  in  great  part  by  the 
shadow,  in  the  bottom  of  the  cavity,  and  applied  upon 
the  serratus  magnus  anticus  muscle. 
21  21  Brachial  branches  of  the  intercostal  nerves. 
22  22  22  Acromial  artery,  originating  from  the  axillary  behind  the 
pectoralis  minor,  and  being  discovered  only  upon  the  fore- 
part of  the  vein. 

24  Croraco-acromion  Ligament,  sliding  under  the  deltoid  muscle. 
25  25  Coraco-acromion  triangle. 

26  Small  arterial  and  venous  branches  of  the  hollow  of  the 

axilla. 

27  Head  of  the  Humerus. 

5  3  25  Clavi-pectoral  triangle,  limited  by  the  pectoral  muscle  be- 
low and  by  the  clavicle  above. 
24  25  25  Coraco-acromion  triangle,  limited  by  the  coraco-clavicular 

^and  coraco-acromion  ligaments. 

24  14  3  3  5  Sub-pectoral  triangle,  circumscribed  by  the  humerus  exter- 
nally, the  pectoralis  minor  muscle  superiorly,  and  the  an- 
terior margin  of  the  axilla  inferiorly. 

PLATE  VI. 

This  figure  represents  the  fold  of  the  arm  in  such  a  manner  as  to  show  the  disposition  of 
the  organs  which  may  be  concerned  in  the  operation  of  Venesection,  etc. 

1  Trunk  of  the  Basilic  vein  in  the  internal  bicipital-gutter  or 

groove 

2  Cephalic  vein  on  the  external  side  of  the  biceps,  and  sepa- 

rated from  the  musculo-cutaneus  nerve  by  the  aponeurosis. 
3  3  Basilic  and  cephalic  veins  of  the  fore  arm,  or  anterior  radial 

and  ulnar  branches. 

4  Sonde  Canelte  placed  under  the  humeral  artery,  above  the 
fibrous  bandelet  of  the  biceps. 


456  EXPLANATION  OF  THE  PLATES. 

5  Common  median  vein,  which  communicates  with  the  deep 

veins,  in  passing  before  the  aponenrotic  aperture,  and 
which  afterwards  divides  in  order  to  form  the  median  ba- 
silic and  median  cephalic. 

6  Posterior  ulnar  vein. 

7  Posterior  radial. 

8  Trunk  of  the  internal  cutaneous  nerve,  placed  on  the  inner 

side  of  the  basilic  vein. 

9  Musculo-cutaneus     nerve,    distributing    itself    especially 

around  the  common  median  vein. 

10  Aponeurotic  bandelet  which  is  detached  from  the  bicipital 

tendon  in  order  to  pass  upon  the  fore  part  of  the  internal 
muscular  mass. 

1 1  Tendon  of  the  biceps  muscle. 

12  12  12  12  12  Circumferences  of  the  aponeurotic  aperture  of  the  elbow, 
strong  and  distinct  internally,  thin  and  blending  itself  ex- 
ternally with  the  cellular  tissue  which  covers  the  external 
muscular  mass. 
13  13  Brachial  Artery. 

14  Radial  Artery. 

15  Cubital  artery,  or  ulnar. 

16  Median  nerve. 

17  17  Brachial  vein  ;  these  last  two  organs,  here  separated  from 
the  artery  by  the  sonde,  rest  upon  the  brachalis  internus 
muscle  before  insinuating  themselves  between  the  fibrous 
bandelet  of  the  biceps  and  the  tendon  of  this  muscle. 

18  20  20  External  muscular  mass. 

19  19  19  Internal  muscular  mass,  covered  in  great  part  by  the  apon- 

eurosis. 

21  Internal  eminence  of  the  elbow  or  epitrochlea. 

22  Hook  which  draws  inwards  the  aponeurotic  aperture,  in  or- 

der to  expose  to  view,  above  the  bandelet  of  the  biceps,  the 
brachial  artery  and  vein,  the  median  nerve,  the  brachialis 
internus  and  pronator  teres  muscfes. 
23  23  Subcutaneous  layer  and  portion  of  the  reflected  skin. 

24  Fore  arm  covered  by  its  integuments. 

25  Inferior  part  of  the  arm  likewise  covered  by  the  skin. 


